y^y-'." 


■■  lillilillliilil   i'  I 


G     000  005  497     3 


SYPHILIS   AND   SIMILAR   DISEASES 
OF  THE  MOUTH 


Zinsser  is  not  a  text-book.  Neither  is  it  a  general 
treatise  on  syphilis.  It  is  a  pictorial  atlas  of  the 
syphilitic  and  kindred  affections  of  the  oral  cavities. 
DIFFERENTIAL  DIAGNOSIS  is  its  main  object. 
Treatment  is  only  indicated.  It  can  be  found  in  any 
reliable  text-book  on  syphilis. 

We  strongly  recommend  to  the  reader  the  following 
books : 

1.  TREATMENT  and  PROPHYLAXIS  of  SYPH- 
ILIS  ($3.00).  By  Alfred  Fournier,  the  greatest  syphi- 
lographer  living.  This  is  still  the  standard  work  on 
Syphilis. 

2.  SALVARSAN  ($5.00).  By  W.  Wechselmann 
(Translatedby  A.  L.  T'P'oZ6ars().  New  Edition.  This  book 
contains  a  number  of  progressive  illustrations,  produced 
by  the  same  process  as  those  contained  in  Zinsser.  It 
is  up  to  date  and  contains  the  technique  and  methods 
of  injection  of  Salvarsan  (illustrated) ;  a  full  account  of 
the  spirochete  pallida;  and  the  serum  diagnosis  of  Syphi- 
lis, according  to  Wassermann. 

3.  TREATMENT  of  SYPHILIS  by  SALVARSAN 
($1.00).     By  /.  Bresler. 

4.  THE  THERAPY  of  SYPHILIS  ($1.50).  By  Paul 
Mulzer.     Just  Issued. 

5.  CLINICAL  CHEMISTRY,  MICROSCOPY  and 
BA CTERIOLOG  Y  ($3. 00) .  By  Klopstock  and  Kowarsky. 
New  Edition.  Just  issued.  With  many  illustrations  (16 
in  Colors) .  This  manual,  besides  all  other  laboratory  tests, 
gives  also  full  and  detailed  instructions  about  the  Spiro- 
chete pallida  and  the  Wasseryyiann  reaction. 

6.  DERMOCHROMES  ($24.00).  By  Jacohi.  3  vol- 
umes, in  full  flexible  leather,  with  gilt  edges  all  around. 
It  is  by  far  the  most  complete  and  handiest  pictorial  atlas 
of  Medical  Skin  Diseases.  248  illustrations  in  natural 
colors,  like  those  in  Zinsser.  In  fact,  Zinsser  is  simply 
a  Supplement  to  Dermochromes. 

7.  CLINICAL  SURGERY im.OO).  By Bockenheimer. 
This  work  contains  150  Ikonograms  depicting  the  Surgi- 
cal Skin  Diseases.  These  illustrations  are  lifelike  and 
unique  and  have  never  appeared  in  any  other  work.  They 
are  prepared  l)y  the  same  process  as  those  contained  in 
Zinsser,  Salvarsan,  and  Dermochromes. 

Descriptive  circulars  will  be  sent  upon  application. 

REBMAN    COMPANY 
1123  Broadway.  New  York 


DISEASES 

OF 


THE    MOUTH 

SYPHILIS    AND    SIMILAR    DISEASES 


FOR 

PHYSICIANS,    DENTISTS,   MEDICAL 
AND  DENTAL  STUDENTS 

BY 
PROF.   DR.    F.   ZINSSER 

DIRECTOR    OF    THE    DEPARTMENT    OF    DERMATOLOGY    AT    THE    CITY 

HOSPITAL,   lindenburg;   dozent  at  the  academy 

FOR    practical    MEDICINE,    COLOGNE 

TRANSLATED   AND    EDITED 

BY 

JOHN   BETHUNE   STEIN,   M.D. 

PROFESSOR    OF    PHYSIOLOGY    AT    THE    NEW    YORK    COLLEGE     OF    DENTISTRY, 

LATE    INSTRUCTOR    IN    GENITO-URINARY    DISEASES    AT    THE    COLLEGE 

OF  PHYSICIANS  AND  SURGEONS  (  MEDICAL   DEPARTMENT  OF 

COLUMBIA    university),     NEW    Y'ORK    CITY 

friTH  52  COLORED  AND  21  BLACK  AND  WHITE  ILLUSTRATIONS 


NEW   YORK 

REBMAN    COMPANY 

HERALD  SQUARE  BUILDING 

141-145  West  36th  Street 


All  rights  riservtd 


VO 


4? 


'^li-^Gfc-oF     ^y 


3lOD 


TO 

HERRN   GEH.    MEDIZINALRAT 
PROF.    DR.    EDMUND   LESSER 


AUTHOR'S   PREFACE 

Some  lectures  and  demonstrations  which  I  insti- 
tuted some  years  ago  suggested  my  writing  this 
work.  It  has  been  proved  that  there  exists  a  need 
for  hicid  and  detailed  instruction  in  the  diagnosis  of 
syphilis  and  similar  diseases  of  the  mouth  of  which 
no  account  has  been  taken  in  spite  of  its  great  im- 
portance. 

This  circumstance  depends  probably  upon  the 
fact  that  the  clinical  material  belonging  to  this  do- 
main of  medicine  is,  as  a  rule,  very  much  scattered; 
appearing  not  only  in  the  dermatological  clinic  but 
also  in  the  clinics  of  laryngology,  surgery,  internal 
medicine,  pediatrics  and  dentistry,  and  making  it 
difficult  to  obtain  a  general  view  of  the  subject.  This 
difficulty  is  especially  marked  in  the  dental  curric- 
ulum, where  the  few  hours  devoted  to  the  clinical 
demonstration  of  syphilis  make  it  necessary  to  resort 
at  times  to  charts  in  order  to  more  fully  present  the 
subject. 

Of  course,  physicians,  dentists,  medical  and  den- 
tal students  lose  much  because  of  this  scattering  of 
clinical  material.  Even  if  it  was  possible  to  attend 
the  clinics  and  polyclinics  regularly  and  for  a  long 
time  in  order  to  obtain  some  experience  in  this  do- 
main of  medicine  a  comprehensive  view  of  it  would 
be  wanting. 

By  the  interest  with  which  experienced  physi- 
cians have  studied  our  collection  of  moulages  of  dis- 
eases of  the  mouth,  I  am  convinced  that  there  exists 

vii 


a  need  for  a  composite  pictorial  representation  of  this 
subject. 

In  the  introduction  I  have  endeavored  to  give  a 
short  review  of  the  course  of  syphilis  and  to  describe 
in  a  few  words  the  diseases  of  the  mouth  resembling 
syphilis,  especially  in  reference  to  their  differential 
diagnosis. 

It  would  by  far  exceed  the  limits  of  this  book  if 
I  should  describe  in  detail  the  clinical  manifestations 
of  these  diseases,  which  frequently  appear  only  as 
partial  manifestations  of  general  diseases. 

This  book  is  intended  to  be  an  illustrated  aid  in 
study  and  diagnosis.  For  a  more  detailed  study  the 
text  books  of  medicine,  surgery,  pediatrics,  laryngol- 
ogy and  dermatology  are  necessary. 

The  therapeutic  side  has  not  been  taken  up,  be- 
cause in  syphilis,  as  in  the  other  mentioned  diseases 
of  the  mouth,  the  therap)^  is  usually  not  only  local  but 
also  general;  consequently,  its  discussion  would  lead 
us  too  far. 

Although  pictorial  representations  are  but  poor 
substitutes  for  clinical  observations,  I  hope  the  pres- 
ent book  will  fulfil  its  task  in  helping  the  study  and 
diagnosis  of  syphilis  and  similar  diseases  of  the 
mouth. 

Dr.  Zinsser. 

Cologne  on  Rhein. 


vni 


EDITOR'S   PREFACE 

Some  years  since,  while  visiting  the  musevim  at 
the  Hospital  of  Saint  Louis,  in  Paris,  I  was  much 
impressed  by  the  teaching  value  of  the  moulages  col- 
lected there,  to  the  number  of  several  thousand. 

In  tlie  few  moulages — showing  typical  primary, 
secondary,  and  tertiarj^  lesions  of  the  buccal  cavity — 
which  I  then  brought  to  this  country,  considerable 
interest  was  showTi,  not  only  by  specialists  in  syphilis 
but  also  by  general  practitioners,  dentists,  and  of 
course  students.  It  was  chiefly  because  of  the  fa- 
vorable manner  in  which  these  moulages  were  re- 
ceived that  I  later,  with  permission  of  the  authorities 
in  Paris,  had  autochrome  lantern  slides  made  of  some 
of  the  moulages  at  the  museum  of  the  Hospital  of 
Saint  Louis,  showing  various  diseases  of  the  buccal 
cavity,  including  hypoplasia  of  the  teeth  of  syphilitic 
origin. 

The  keen  interest  shown  in  these  lantern  slides 
and  in  my  remarks  thereon  at  the  several  meetings 
of  physicians  and  dentists  where  they  were  exhibited, 
manifest  unmistakably  a  desire  on  the  part  of  mem- 
bers of  both  professions  in  this  country  for  a  further 
and  more  complete  exposition  of  the  nature  and  diag- 
nosis of  the  diseases  to  which  these  pictures  relate,  in 
the  light  of  present-daj^  scientific  knowledge. 

The  recent  advancement  in  the  study  of  the 
nature,  diagnosis,  and  treatment  of  syphilis  is  so 
great  that  a  statement  of  it  amounts  to  a  revelation, 
and  Professor  Zinsser's  "Syphilis  and  Similar  Dis- 

ix 


eases  of  the  ^Mouth"  is  abreast  of  the  foremost  ex- 
positions of  modern  medical  science.  I  am  confident, 
therefore,  that  this  edition  will  be  appreciated  by 
English-speaking  physicians  and  dentists,  who  should 
find  tlie  work  of  considerable  practical  value. 

In  the  translating  and  editing  of  his  work,  I  have 
of  course,  endeavored  to  give  a  clear  and  accurate 
reproduction  of  Professor  Zinsser's  views,  which  I 
have  supplemented  by  the  addition  of  some  matter 
chiefly  relating  to  the  Spiroch^etsE,  the  Wassermann 
reaction,  luetin  (Noguchi),  etc.,  and  I  have  inserted 
four  drawings  made  for  me  by  one  of  my  students, 
Mr.  Francis  Ovary. 

John  Bethune  Stein. 

New  York  City. 


TABLE  OF  CONTENTS 

PAGE 

Introduction 1 

The  Primary  Lesion  of  Syphilis 12 

Secondary  Syphilis 20 

Tertiary  Syphilis 28 

Heredosyphilis 34 

Diseases  Similar  to  the  Lesions  of  Secondary  Syphilis 

OF  THE  Mouth 45 

Diseases  Similar  to  the  Lesions  of  Tertiary  Syphilis 

OF  THE  Mouth 59 

Index 263 


XI 


LIST  OF  ILLUSTRATIONS 

no.  PAGE 

1.     Chancre  of  the  Upper  Lip  (Chancrous  Erosion)   .       71 

8.     Two  Chancres  of  the  Lower  Lip 75 

8.     Chancre  of  the  Tongue 79 

4.     Syphilitic  Erytlicma  of  the  Mucous  Membrane  of 

the  Mouth 83 

6.     Erosive   Mucous   Patches   of  the  Lower  Lip   and 

Condjioniata  Lata  of  the  Naso-Labial  Folds     .        87 

6.  Erosive  Mucous   Patches  of  the  Upper  Lip  and 

Tongue 91 

7.  Hypcrtrophied  Mucous  Patches  of  the  Tongue  and 

Lips 95 

8.  Papulo-Ulcerated     Syphilide    of    the    Lips     and 

Tongue  (Ulcerated  ]Mucous  Patches)    ...       95 

9.  Ulcerated  Syphilide  of  the  Lips  (Ulcerated  Mu- 

cous Patches) 99 

10.  An  Ulcerated  Annular  Syphilide  of  the  Lower  Lip 

Resembling  a  Serpiginous  Ulcer      ....     103 

11.  Opaline  Mucous  Patches  of  the  Tongue      .       .       .107 

12.  Papulo-Ulcerated  Syphilide  of  the  Tongue      .       .107 

13.  Glossitis  Syphilitica  (Syphilitic  Glossitis).      .      .     113 

14.  Ulcerated  Mucous  Patches  of  the  Tongue      .       .113 

15.  Angina  Syphilitica  (Syphilitic  Angina)    .       .       .117 

16.  Papules  of  the  Soft  Palate  and  Uvula      ...     121 

17.  Annular  Syphilide  of  the  Mucous  Membrane  of 

the  Soft  Palate,  Uvula,  and  Pillars  of  the  Fauces     125 
xiii 


PIG.  PAGE 

18.  Hypertrophied  Mucous  Patch  of  the  Soft  Palate 

and  Uvula 129 

19.  Angina  Ulcerosa   (Ulcerated  Syphilitic  Angina).     133 

20.  Circinate  Mucous  Patches  About  the  Mouth  and 

Nose 137 

21.  Gummatous  Ulcers  of  the   ^lucous  Membrane  of 

the   Hard    Palate 141 

22.  Tertiary  Syphihs,  Perforation  of  the  Hard  Palate, 

Periostitis  of  the  Processus  Alveolaris      .       .       .145 

23.  Gummatous  Destruction  of  the  Soft  Palate      .       .149 

24.  Ulceration  of  the  Fauces  in  Malignant  Syphilis      .     153 

25.  Malignant   Syphilis  of  the  Fauces      ....     157 

26.  Sj'philis  Hereditaria  (Heredosyphilis).      .       .       .     161 

27.  Syphilis  Hereditaria  Tarda  (Late  Heredosyphilis)     165 

28.  Syphilis  Hereditaria  Tarda   (Late  Heredosyplii- 

lis).     Gumma  of  the  Tongue 169 

29.  Syphilis  Hereditaria   Tarda   (Late  Heredosyphi- 

lis).     Gummatous    Perforation    of    tlie    Hard 
Palate    and    Heredosyphilitic    Teeth      .       .       .      169 

30.  Stomatitis  Mercurialis  (IMcrcurial  Stomatitis)      .     175 

31.  Stomatitis  Mercurialis  (Mercurial  Stomatitis  with 

Ulcerations  on  the  Border  of  the  Tongue)      .     175 

32.  Angina  Mercurialis  (Mercurial  Angina)   .  .     179 

33.  Antipyrin  (Salipyrin)   Exantheni  of  tlie  Tongue     185 

34.  Lichen  Ruber  Planus  of  tlie  Buccal  Mucous  Mem- 

brane       185 

35.  Erytiicma  Exudativum  ^Multiforme  of  the  IMucous 

Membrane    of    tlie    Moutli     ( Idiopathic     Poly- 
morphous Erytiicma) 189 

36.  Herpes  Labialis   (Herpes  of  the  Lip)      .       .       .     193 

37.  Ajihthous  Ulcer  (Apiithous  Stomatitis)      .       .       .     197 

38.  Angin/i  Foilicuhiris  Catarrlialis  (Follicular  Tonsil- 

litis)  197 

xiv 


PIG.  PAOB 

39.  Angina    Syphilitica  ct    Angina    Follicularis    Ca- 

tarrlialis     (Syphilitic    Angina    and    Follicular 
Tonsillitis) 201 

40.  Diphtheria 201 

41.  Plaut-Vincent    Angina     (Ulcerated    Angina    Re- 

sembling a   Chancre  of  the  Tonsil)      .       .       .     205 

42.  Angina    Ulcerosa   Traumatica    (Ulcerated    Trau- 

matic Angina).      {Plaut-Vincent  Angina.'')  209 

43.  Angina    Mycotica    (Mycotic    Angina)      .       .       .  213 

44.  Lingua  Geographica  (The  Geographical  Tongue)  219 

45.  Lingua  Geographica  (The  Geographical  Tongue)  219 

46.  Leukoplakia  Linguas  (Leukoplakia  of  the  Tongue)  223 

47.  Tuberculosis  of  the  Mucous  Membrane  of  the  Hard 

Palate 223 

48.  Tuberculosis    of    the    Mucous    Membrane    of    the 

Fauces,  Soft  Palate,  and  Uvula      ....     227 

49.  A  Tubercular  Ulcer  of  the  Lower  Lip  ....     231 

50.  Carcinoma    of    the    Tongue 235 

51.  Tumor   of  the  Tongue.      Gumma.''      ....     235 

52.  53.     Hutchinson  Teeth 239 

54,  55,  56,  57.      Heredosyphilitic  Teeth      .... 
58,  59,  60,  61.     Heredosyphihtic  Teeth       .... 

62.  Heredosyphilitic    Teeth 

63,  64,  65,  66.     Heredosyphilitic  Teeth      ....     249 

67.  Heredosyphilitic    Teeth 249 

68.  Treponema  Pallidum  (Spirocha?ta  Pallida).     Tlic 

Specimen  was  Obtained  from  a  Mucous  Patch  of 

the    Lip 253 

69.  Spirochsta    Buccalis    and    Spirochwta    Dentium 

(Treponema    Microdentium).       The    Specimen 

was  Obtained  from  a  Healthy  Mouth  .      .     253 

XV 


FIG.  PAGE 

70.  Treponema    Pallidum,    Pus    Cells,    Erythrocytes, 

and    Cocci 257 

71.  Treponema  Microdentium  ( Spirocliieta  Dentium), 

Treponema  Macrodentium  ("Medium  Form"  of 
Hoffmann  and  von  Prowazek),  Spirochaeta  Buc- 
calis 257 

72.  Spirocha'ta  of  Vincent  and  Bacillus  Fusiformis  of 

Vincent,  Pus  Cells 261 

73.  The  Chronolocfv  of  the  Calcification  of  the  Teeth    261 


XVI 


Introduction 

Syphilis  is  a  chronic  infectious  disease  caused  by 
a  specific  microorganism,  the  treponema  pallidum 
(spirochajta  pallida).  The  primary  lesion  of  syph- 
ilis or  chancre  (initial  lesion,  primary  sclerosis)  de- 
velops at  that  point  on  the  body  which  serves  as  a 
port  of  entrance  for  this  microorganism.  The  in- 
fection spreads  through  the  whole  organism,  rapidly 
by  the  blood  and  slowly  by  the  lymphatics. 

In  the  secondary  period  of  syphilis,  the  manifes- 
tations of  the  disease  may  appear  in  any  organ  of  the 
body.  Occasionally  they  are  ushered  in  with  fever, 
swelling  of  the  spleen,  and  general  systemic  disturb- 
ances, whicli  syndrome  may  run  a  chronic  course  for 
about  a  year.  It  is  possible  for  syphilis,  during  the 
secondary  period,  to  run  an  exceptionally  light 
course,  to  confine  itself  to  a  single  transitory  and 
scarcely  observable  erythema,  which  occasionally 
may  even  fail  to  appear  or  may  escape  observation. 
Regularly,  in  the  course  of  the  first  months  and  years 
following  more  or  less  intense  general  manifestations 
of  the  disease,  general  or  local  expressions  of  syph- 
ilis alternate  with  latent  periods,  when  no  symptoms 
appear.  Gradually  the  disease  subsides,  not  to  re- 
appear; usually  under  the  influence  of  treatment; 
seldom  without  it.  In  a  certain  number  of  cases  it 
may  reappear,  after  a  more  or  less  long  latent  period, 
in  the  form  of  tertiary  syphilis,  or  ripen  in  the  worst 
form  as  a  parasyphilosis. 

In  contrast  to  the  secondary  period,  tertiary  syph- 
ilis is  to  be  looked  upon  more  as  a  local  rather  than 
as  a  constitutional  disease.  It  is  usually  a  local  flam- 
ing up  of  the  disease  in  a  place  where,  for  years,  the 

1 


causal  agent  has  been  preserved  and  remains  dor- 
mant. Tertiary  syphilitic  lesions  are  mostly  solitary 
or  sporadic. 

What  tertiary  syphilis  loses  in  extensiveness  it 
riclily  gains  in  hitensiveness.  It  distinguishes  itself 
by  the  development  of  neoplasms  of  inflammatory 
origin,  which  quickly  grow  and  extend.  The  embry- 
onic cells  of  this  syphilitic  inflanmiation  may  undergo 
either  a  fibrous  transformation  or  a  rapid  necrobio- 
sis. This  necrobiosis  or  necrosis  of  the  neoplasm 
compromises  not  only  the  function  of  the  organ  in- 
volved, but  may  menace  the  life  of  the  patient.  The 
interim  between  the  beginning  of  the  secondary  pe- 
riod and  the  occurrence  of  tertiary  lesions  varies 
greatly.  There  are  cases  where  tertiary  manifesta- 
tions appear  sjTichronously  or  alternately  with  sec- 
ondary lesions.  One  may  be  apparently  healthy  for 
years  before  the  apj^earance  of  tertiary  lesions.  The 
tertiary  period  begins  most  often  about  five  or  six 
years  after  tlie  primary  lesion.  But  cases  have  been 
reported  with  latent  periods  of  fifteen,  twenty,  thirty,* 
and  even  fifty  and  sixty  years'  duration  after  the  in- 
fection. 

The  cause  of  the  appearance  of  late  tertiary  syphi- 
litic manifestations  in  one  case  and  not  in  another 
is  unknown.  The  only  thing  that  one  can  say  with 
any  degree  of  security  is,  tliat  the  frequency  of  the 
late  manifestations  of  syphilis  is  directly  dependent 
upon  the  thoroughness  of  the  treatment  in  the  sec- 
ondary period.  The  more  energetic  the  treatment  so 
niucli  less  frequently  the  appearance  of  tertiary  le- 
sions and  vice  versa.  [Treatment  should  be  begun 
as  soon  as  the  diagnosis  of  the  chancre  has  been 
madc.--Ti{.] 

Of  still  greater  significance  than  the  tertiary 
syphilidcs  arc  the  so-called  post-syphilitic  manifesta- 
tions, or  parasyphiloses;  that  is,  such  pathological 
conditions  whicli  if  not  of  a  specific  syphilitic  charac- 
ter are  due  to  or  occasioned  by  the  sypliilitic  infection. 

2 


Among  these  are  tabes,  dementia  paralytica,  many 
cases  of  arteriosclerosis,  aneurysm,  amyloid  degen- 
eration, etc.  By  the  presence  of  these  sequelse  it  is 
possible  to  determine  the  intensity  of  the  early  syphi- 
litic treatment. 

No  disease  plays  such  a  role  in  transmitting  itself 
to  posterity  as  syphilis.  It  is  not  a  question  of  in- 
heriting the  disease,  but  a  direct  infection  of  the  em- 
bryo or  foetus  exclusively  by  the  syphilitic  mother. 

At  any  time  during  pregnancy  the  disease  can  be 
transmitted  to  the  embryo  or  foetus.  With  an  early 
infection  or  with  severe  syphilitic  involvement  of  the 
placenta  the  foetus  dies  and  abortion  takes  place. 
This  occurs  for  the  most  part  during  the  third  to  the 
sixth  month  of  pregnancy.  No  other  cause  inter- 
rupts pregnancy  so  often  as  syphilis.  If  the  foetus 
survives  the  syphilis  in  utero,  it  comes  into  the  world 
afflicted  with  the  disease;  the  manifestations  showing 
themselves  more  or  less  soon  after  the  infection.  It 
is  obvious  that  a  severe  chronic  infection  of  the  new- 
born endangers  its  life  and  often  leads  to  such  severe 
damage  that  the  traces  of  it  are  never  entirely  re- 
moved. 

A  peculiar  characteristic  of  syphilis  is  the  numer- 
ous phases  and  various  manifestations  of  the  disease 
during  the  sometime  long  period  of  the  duration. 
Even  if  syphilis  spares  no  organ  and  its  manifesta- 
tions occur  in  all  possible  parts  of  the  body,  it  has, 
however,  a  special  predilection  for  certain  parts. 
The  most  frequent  point  of  infection  is  about  the 
genitals,  because  coitus — entirely  in  a  mechanical 
way — favors  the  transmission  of  syphilis,  and  the  in- 
fections of  the  mouth,  which  are  comparatively  fre- 
quent, are  also  mechanically  brought  about  by  direct 
or  indirect  contact. 

The  secondary  manifestations  of  syphilis  have  a 
predilection  for  the  skin  and  mucous  membranes. 
The  acute  eruption  usually  distributes  itself  over 
the  entire  body,  but  most  intensely  on  predisposed 

3 


places,  and  in  cases  of  later  relapses,  almost  exclu- 
sively on  such.  In  order  to  understand  the  localiza- 
tion of  syphilitic  manifestations  it  is  important  to 
know  that  secondary  and  tertiary  syphilis  establish 
themselves  A^ith  predilection  and  intensity  on  such 
spots  as  have  been  determined  by  irritation  and  in- 
jury. ^Ve  often  see  condylomata  lata  on  places 
where  the  skin  is  rubbed  and  macerated  by  the  sweat ; 
as,  the  buttocks,  about  the  external  genitalia,  under 
the  breasts  and  between  the  toes.  The  eruption  is 
most  pronounced  on  those  places  which  are  irritated 
by  the  pressure  of  suspenders,  garters  and  belts,  and 
secondary  and  tertiary  periostitis  occurs  on  those 
bones,  tibia,  clavicle  and  bones  of  the  skull,  which 
being  directly  under  the  skin  are  most  frequently 
subjected  to  trauma. 

For  this  same  reason  secondary  syphilis  has  an 
especial  predilection  for  the  mouth,  as  the  mucous 
membrane  of  the  mouth  and  tongue  is  continually  ir- 
ritated by  eating,  drinking,  biting,  smoking,  unequal 
surface  (juality  of  the  teeth,  and  tartar,  etc.  For- 
eign bodies  and  many  different  kinds  of  microorgan- 
isms may  lodge  upon  the  tonsils,  thus  leading  to  in- 
flammation. The  lips  are  often  chapped,  and  there 
may  be  slight  injuries  to  the  epithelium.  As  no 
other  mucous  membrane  of  the  body  is  subjected  to 
as  much  trauma  as  that  of  the  mouth,  the  manifesta- 
tions of  syphilis  occur  in  and  about  this  locality  more 
frequently  than  upon  any  other  part  of  the  body. 

Tertiary  syi)hilitic  lesions  of  the  mouth  are  com- 
])aratively  frequent.  The  mucous  membrane,  how- 
ever, is  not  so  often  involved  as  the  underlying  tis- 
sue, viz.,  the  muscle  and  bone.  Destruction  of  the 
soft  palate,  pcrloration  of  the  hard  palate,  and  ne- 
crosis of  the  roof  of  the  mouth  are  not  infrequent 
sequelaj  of  tertiary  syphilis. 

Ilerc'dosyphilis  makes  itself  evident  in  the  mouth 
and  its  adnexa,  not  only  in  the  early  but  also  in  the 
late  forms  of  syphihs,  as  tertiary  lesions,  leading  at 

4 


times  to  considerable  destruction  of  the  bones.  De- 
formities of  tlie  teeth  following  heredosyphilis  are  of 
quite  frequent  occurrence,  and  of  great  importance. 

Leukoplakia  buccalis  is  a  post-syphilitic  lesion. 

We  are  therefore  able  to  observe  in  the  mouth  all 
stages  of  syphilis  and  to  a  certain  extent  study  in  the 
syphilitic  oral  manifestations  a  paradigm  of  the  en- 
tire course  of  syphilis. 

As  the  mouth  and  its  adnexa  are  especiallj^  ex- 
posed to  irritation,  trauma,  and  infection,  a  large 
number  of  diseases  other  than  syphilis  may  involve 
these  localities,  such  as  catarrh,  the  various  forms  of 
angina,  thrush,  diphtheria,  etc.  Many  acute  or 
chronic  infectious  diseases  cause  or  complicate  le- 
sions of  the  mouth  and  pharynx,  and  with  some  skin 
diseases  the  eruption  sometimes  invades  the  bucco- 
pharjaigeal  mucous  membrane.  Consequently  the 
differential  diagnosis  of  such  conditions  is  very  im- 
portant and  often  difficult. 

As  the  clinical  picture  of  syphilis  varies  greatly, 
and  as  syphilis  of  the  mouth  may  resemble  many 
other  diseases  occurring  in  this  locality,  a  diagnosis 
cannot  be  made  by  considering  the  clinical  manifes- 
tations alone:  to  them  must  be  added  a  thorough  ex- 
amination of  the  entire  body,  a  consideration  of  the 
anamnesis  and  course  of  the  disease,  accompanied  by 
bacteriological,  microscopical,  serological  examina- 
tion and  sometimes  even  inoculation  experiments. 

The  causal  agent  of  syphilis  is  the  Treponema 
Pallidum  {Spirochceta  Pallida)  (Figs.  68  and  70), 
discovered  by  Schaudinn  in  1905.  It  is  pale,  has  an 
average  length  of  about  ten  to  twenty  microns;  its 
thickness  is  only  .2.5  of  a  micron.  It  has  no  undulating 
membrane;  is  circular  in  transverse  section,  and  has 
finely  pointed  ends.  The  spiral  or  corkscrewlike 
form  is  constantly  maintained  by  the  spirochjeta,  both 
while  resting  or  moving.  Tlie  turns  of  the  spirals  are 
deep,  regular,  close  together,  and  vary  from  six  to 
twelve  and  may  even  be  twenty-six  in  number.    It 

5 


is  markedly  elastic  and  not  easily  deformed.  [In 
vitro  its  vitality  is  not  great,  and  its  movements  cease 
in  five  or  six  hours  at  room  temperature.  It  is  diffi- 
cult to  stain  and  is  colored  red  by  Giemsa. — Tr.] 

The  treponema  pallidum  moves  by  rotation 
around  its  long  axis,  comparatively  slowly,  at  times 
forward,  sometimes  it  stops  and  may  move  in  the 
opposite  direction.  There  are  also  undulating,  flex- 
ion and  extension  movements.  [The  movement  of 
the  other  spirochajt.t,  except  the  treponema  micro- 
dentium  (spirochcVta  dentium),  is  for  the  most  jjart 
sinuous  or  snakelike,  and  there  is  also  a  tendency  to 
lengthen  their  spirals  during  rest. — Tk.] 

The  treponema  pallidum  has  been  found  in  the 
chancre  and  adenopathies  accompanying  the  same ;  in 
secondary  manifestations  (mucous  patches,  papules 
roseola,  etc. ) ,  and  in  the  blood  of  the  general  circu- 
lation. [The  treponema  pallidum  has  not  been  found 
in  the  semen;  but  during  the  secondary  period  of 
the  disease  this  secretion  has  been  proved  infectious. 
Tertiary  syphilis  is  said  to  be,  clinically,  not  infec- 
tious; however,  the  causal  agent  has  been  encoun- 
tered in  j)ai)ular  tertiary  lesions  and  gummata. 
Apes  which  have  been  inoculated  with  fragments 
of  gummata  and  the  blood  from  persons  having 
tertiary  syphilis  contracted  the  disease.  It  has  also 
been  found  in  the  aorta  in  syphilitic  aortitis.  In  the 
lesions  of  hcrcdosyphilis  the  pallidum  is  found  in 
greatest  numbers,  and  may  also  be  encountered  in 
any  organ.  It  is  found  in  the  placenta,  and  may  be 
found  even  within  the  ovocytes.  It  is  almost  always 
present  in  the  mucus  from  the  mouth,  tonsils, 
pharynx  and  nose  of  heredosyphilitics. 

Syi)hilis  has  been  produced  in  the  ape  by  inocu- 
lating it  with  the  nasal  mucus  from  a  syi)hilitic  man. 
In  U>():j.  Itoux  and  Mctchhikoff  demonstrated  that 
anthropoid  apes  are  susceptible  to  syphilis.  It  is, 
however,  not  so  easily  generalized  in  animals  as  in 
man.     A  sypiiilitic  keratitis  and  orchitis  can  be  pro- 

6 


duced  in  a  rabbit,  a  keratitis  in  a  guinea-pig,  and  the 
cat,  dog  and  sheep  can  be  infected  through  the  cor- 
nea. Syphilis  has  also  been  produced  in  a  two  days' 
ohl  mouse  by  a  subcutaneous  inoculation  of  syphi- 
litic material. — Tu.] 

The  trcponema  pallidum  is  not  easy  to  find  in  the 
lesions  of  malignant  or  tertiary  syphilis.  [The  micro- 
organisms are  probably  encapsulated  in  some  lymph 
node  or  old  diseased  spot,  and  thus  escape  detection. 
It  is  ditKcult  to  find  them  in  latent  syphilis;  but  their 
presence  has  been  proved  in  this  period  of  the  dis- 
ease in  the  fluid  obtained  by  ijuncturing  a  lymph 
ganglion.  It  is  very  difficult  and  only  possible  to 
find  the  treponema  pallidum  in  the  blood  when  there 
is  some  general  manifestation  of  the  disease. — Tr.] 

The  treponema  pallidum  has  been  successfully 
cultivated,  and  its  specificity  has  been  demonstrated 
in  that  it  has  fulfilled  all  the  conditions  of  Koch's 
law. 

The  Spirochccta  Refringens  is  found  in  smegma 
and  in  ulcerated  lesions  of  the  skin  and  may  be  as- 
sociated with  the  treponema  pallidum  in  syphilitic 
lesions,  but  is  usually  met  with  on  the  surfaces  of  the 
lesion  and  not  in  the  deeper  part  where  the  tre- 
ponema pallidum  is  found.  The  spirochseta  re- 
fringens is  thicker  and  longer  than  the  treponema 
pallidum,  and  when  alive  very  refringent  and  pre- 
sents a  number  of  flat,  irregular  open  curves;  its 
movement  being  more  rapid  than  that  of  the  pal- 
lidum and  not  easy  to  follow  under  the  microscope. 
It  is  easy  to  stain  and  colors  blue  with  Giemsa,  and 
can  be  readily  distinguished  from  the  treponema 
pallidum. 

[Two  species  of  spirochatas  have  been  demon- 
strated in  ulcerated  cancers,  viz.:  The  Spirochceta 
Micro-girata  and  the  Spirochceta  Loetventhalii, 
which  differ  markedly  from  the  treponema  pallidum. 
— Tr.] 

In  a  tropical  disease,  Frambesia  (Yaws,  Plan), 

7 


a  spirochfEta  is  found — Spirochceta  Pertenuis  or  Pal- 
lidula  {Castallani)  or  Treponema  Pertenue — which 
in  morphology  and  in  its  staining  properties  with 
Giemsa  cannot  be  distinguished  from  the  treponema 
palhduni. 

Three  forms  of  spirochtetje  are  very  often  found 
in  the  healthy  mouth,  viz.:  the  Spirochceta  Buccalis 
[Cohn,  1875),  Spirocha;ta  Dentiiun  {Koch,  1877) 
(Treponema  Microdentium)  [and  the  "Medium 
Form"  of  Hoffmann  and  von  Protcazek  (Treponema 
Macrodentium). — Te.]  The  Spirochceta  Buccalis 
(Figs.  69  and  71)  is  thick  and  bulky,  with  elongated 
irregular  curves,  and  in  movement  and  appearance 
resembles  the  spirochata  refringens.  The  spiro- 
chjeta  buccalis  and  "medium  form"  (Fig.  71)  are 
frequently  found  in  the  mucus  about  the  tonsils  and 
pharynx,  and  in  great  numbers  in  ulcerative 
stomatitis. 

The  Treponema  Microdentium  (Spirochxta 
Dentin m)  (Figs.  09  and  71),  is  found  in  the  mouth, 
especially  at  the  margins  of  the  gums  and  in  the  cavi- 
ties of  carious  teeth,  and  is  more  likely  to  be  mis- 
taken for  the  treponema  pallidimi  than  any  other 
microorganism.  The  spiral  form,  as  in  the  tre- 
ponema i)allidum,  persists  in  this  microorganism,  even 
during  rest.  [It  moves  by  rotating  around  its  long 
axis  and  has  no  flexion  movements.  It  further  re- 
sembles the  treponema  pallidum  by  being  pale  with 
little  refringence,  with  its  spirals  close  together,  very 
regular,  but  the  curves  are  not  so  high  as  the  pal- 
lidum. Its  average  length  is  about  four  to  ten  mi- 
crons. It  has  been  successfully  cultivated.  Noguchi 
has  found  tliat  the  treponema  microdentium  grown 
upon  his  medium  produces  an  odor,  whereas  the 
cultures  of  the  treponema  jjallidum  on  the  same  me- 
dium are  odorless.  This  organism  is  more  easily 
stained  tlinn  the  trci)oiKMiia  ])allidum. — Tr.] 

['J'lic  Spirochnla  of  Vincent,  associated  with  the 
Bacillus  Fusiformis  of  Vincent  (Fig.  72)  in  Plaut- 

8 


Vincent  angina,  has  the  characteristics  of  the  spiro- 
cha?ta  buecahs,  and  may  be  confused  with  it.  It  is 
chiefly  found  in  the  mouth,  and  may  possibly  be  a 
saprophytic  microorganism  in  that  locality. — Tr.] 
It  stains  blue  with  Giemsa. 

In  the  differential  diagnosis  of  the  spirocluetfe  of 
the  mouth,  the  greatest  caution  is  required,  because 
of  their  close  resemblance  to  one  another.  A  smear 
may  be  made  from  the  exudate  of  the  suspected 
lesion  and  stained,  or  the  method  of  Burri  ( India  ink 
method)  may  be  used  to  find  the  microorganism. 
The  best  method  for  determining  the  presence  of  the 
treponema  pallidum  or  other  spirochaetas  is  by  means 
of  the  dark-field  microscope  {dunkelfeld-  or  idtra- 
microscopc) ,  which  permits  the  study  of  not  only 
the  form  but  the  refringence  and  movements  of  the 
living  organism. 

Formerly,  it  was  necessary  to  watch  the  further 
course  of  the  separate  symptoms  of  syphilis  until  a 
positive  diagnosis  of  syphilis  could  be  made;  thereby 
losing  much  valuable  time  before  treatment  was  com- 
menced. To-day,  however,  by  proving  the  presence 
of  the  treponema  pallidum,  a  diagnosis  can  at  once 
be  made  and  the  disease  immediately  treated. 

The  Sero-rcaction  of  Wassermann  is  at  times 
an  important  aid  in  detecting  syphilis.  The  reaction 
depends  upon  the  fact  that  in  the  body  the  living 
causal  agents  of  a  given  disease  produce  or  incite 
the  cells  of  the  body  to  produce  a  substance,  which  is 
knowTi  as  the  immune  body,  or  antibody.  These  ex- 
ceptionally delicate  and  labile  substances  have  not 
been  analyzed,  but  through  a  biological  reaction 
their  presence  influences  the  capability  of  the  blood 
serum  to  dissolve  the  erythrocytes  of  another  animal 
species. 

The  serodiagnosis  of  syphilis  introduced  into  the 
practice  of  medicine  by  v.  Wassermann,  Xeisscr  and 
Bruck,  in  190.5,  is  the  application  to  sy])hilis  of  a 
method  for  the  deviation  of  the  complement  [discov- 

9 


ered  by  Jules  Bordet  and  Octave  Gengoit,  in  1901. 
Widalcalls  it  the  "reaction  of  fixation."— Tr.]  The 
Bon-syphihtic  gives,  with  very  few  exceptions,  a  nega- 
tive reaction.  The  reaction  may  be  positive  in  the  fol- 
lowing diseases,  viz.:  (1)  in  leprosy  and  some  trop- 
ical diseases,  (2)  in  the  last  stages  of  tuberculosis  and 
carcinoma,  (3)  during  the  febrile  movement  of  some 
systemic  diseases.  Scarlatina  occasionally  gives  a 
positive  reaction,  which  does  not  last  long.  All  these 
diseases  are  easy  to  differentiate  from  syphilis,  or  do 
not  occur  among  us.  In  manifest  syphilis  the  reac- 
tion is  almost  always  jjositive.  The  reaction  is  usu- 
ally not  positive  until  the  seventh  week  after  the  ap- 
pearance of  the  chancre,  although  it  has  been  found 
positive  four  to  six  weeks  after  the  infection.  With 
the  occurrence  of  the  general  manifestations  the  re- 
action becomes  positive  in  95  per  cent,  of  the  cases. 
In  tertiary  syphilis  tlie  reaction  is  positive  in  80  per 
cent,  of  the  cases.  From  the  reaction,  especially  if 
it  be  positive,  conclusions  can  be  draAMi  for  diag- 
nosis. In  long-standing  latent  syphilis  the  number 
of  positive  reactions  are  much  fewer.  Latent  syphi- 
lis often  gives  a  weak  reaction;  30  per  cent,  incom- 
plete, 20  per  cent,  positive,  and  50  per  cent,  negative. 
Untreated  cases  of  latent  syphilis  are  more  likely  to 
give  a  positive  reaction  than  well-treated  cases  where 
the  reaction  when  positive  is  weak.  Time  and  e\\)e- 
rience  will  show  the  value  of  the  reaction  in  long- 
standing latent  syphilis.  Are  cases  of  long-standing 
latent  syphilis  giving  a  negative  reaction  cured? 
Are  those  giving  a  positive  reaction  uncured?  Is  the 
positive  reaction  in  such  cases  a  sign  of  complete  im- 
munity following  the  disease?  The  positive  reac- 
tion indicates  the  necessity  for  continuation  of  treat- 
ment. The  serum  of  the  patient  should  be  examined 
at  fretjuent  intervals  during  the  course  of  whatever 
treatment  is  employed,  in  order  to  ascertain  how  the 
treatment  affects  an  ini])ortant  symj)tom  of  the  dis- 
ease, viz.:  the  deflection  of  the  complement.     The 

10 


(Trave  post-syphilitic  diseases — tabes  aiul  dementia 
paralytica — occurriiif^-  after  a  long  latent  period  of 
the  disease  almost  invariably  give  a  positive  reac- 
tion. 

The  Waftscrmanti  reaction,  while  being  a  very 
valuable  means  for  supporting  our  diagnosis  in  cases 
where  we  are  in  doubt  as  to  whether  the  manifesta- 
tions of  a  disease  are  or  are  not  syphilitic,  does  not 
prove  the  tumor  we  have  before  us  is  a  sj'philitic 
nco])lasni,  or  carcinoma,  as  it  is  to  be  remembered 
that  a  man  having  a  chronic  or  latent  syphilis  may 
also  be  afflicted  with  some  other  disease.  In  doubtful 
cases  a  positive  Wassermann  favors  a  diagnosis  of 
syphilis  and  influences  the  treatment. 

Too  much  reliance  should  not  be  placed  upon 
the  Wassermann  reaction  alone;  its  great  value  in 
diagnosis  is  found  when  taken  in  conjunction  with 
the  clinical  picture,  anamnesis,  etc. 

A  single  Wassermann  test  showing  a  negative 
reaction  has  no  diagnostic  worth.  It  is  only  good  for 
the  time  when  it  is  made.  In  general,  we  can  say 
that  the  positive  Wassermann  reaction  has,  in  the 
diagnosis  of  syphilis,  the  same  value  as  a  positive 
syphilitic  anamnesis. 

[Noguchi  claims  that  luetin  (NogucJii)  produces 
a  cutaneous  reaction  in  syphilitic  and  parasyphilitic 
patients,  which  is  most  constant  and  severe  in  the 
tertiary  and  hereditary  affections,  100  per  cent,  of 
manifest  tertiary  affection,  94  per  cent,  of  latent 
tertiary  affection,  96  per  cent,  of  hereditary  affec- 
tion. This  test,  in  conjunction  with  the  Wasser- 
mann, may  facilitate  the  diagnosis  in  difficult  and 
obscure  cases. — Tr.] 


11 


The  Primary  Lesion  of  Syphilis 

Extra  genital  chancres  constitute  about  8%  to 
9%  of  the  entire  number  of  primary  syphilitic  lesions, 
and  75%  of  these  are  situated  on  the  head.  Founiier, 
in  his  well-known  statistics,  states,  that  of  1,124. 
extragenital  primary  lesions,  849  were  upon  the 
head.  Of  these,  567  were  upon  the  lip;  75  on  the 
tongue;  69  on  the  tonsils;  11  on  the  gums;  and  1 
on  tlie  mucous  membrane  of  the  cheek. 

The  fairly  frequent  occurrence  of  a  primary 
lesion  in  or  about  the  mouth  is  not  remarkable  when 
we  consider  how  easily  an  injury,  such  as  a  scratch 
or  break  of  the  skin  or  mucous  membrane,  can  hap- 
pen to  these  structures.  The  following  are  some  of 
the  conditions  which  predispose  these  parts  to  infec- 
tion, viz. :  small  tears  and  fissures,  excoriations  of  the 
lips,  the  hal)it  of  chewing  the  lip,  chapped  lips  which 
are  cracked  or  where  the  underlying  epithelium  is 
exposed,  eczema  of  tlie  lips  (especially  if  mouth 
washes  are  used  which  continually  irritate  them). 
Injury  to  the  tongue  by  biting  or  by  a  sharp  tooth, 
etc. 

In  order  to  contract  syphilis  it  is  necessary  that 
the  port  of  entrance  for  the  treponema  pallidum  must 
cr)mc  in  contact  with  citlicr  the  exudate  of  a  chancre 
or  mucous  patch  or  with  some  material  containing  the 
treponema  pallidum.  Aside  from  this,  the  disease  is 
contracted  bj-^  perverse  sexual  relations,  as  coitus  per 
OS,  cumiilingus,  etc.  Not  infrequently  syphilis  is 
caused  by  a  kiss,  for  the  causal  agent  of  sy])hilis  has 
a  predilection  for  the  mucous  mcml)rane  of  tiie  mouth, 
and  this  is  especially  marked  during  the  secondary 

12 


period  of  the  disease.  These  lesions  of  the  mouth  are 
frequently  so  insignificant  tliat  they  are  not  noticed, 
yet  they  are  extremely  infections,  as  the  treponema 
pallidum  is  found  in  them  and  passes  into  the  saliva  in 
great  numbers.  The  danger  of  promiscuous  kissing  is 
obvious,  and  wherever  it  obtains  tlie  relative  number 
of  tongue  and  lip  chancres  increases,  and  among  some 
peoples  and  in  some  localities  the  chancres  of  the  lips 
are  seen  very  often.  In  Cologne,  every  year  during 
the  carni\'al  time,  the  number  of  primary  lesions  in 
the  mouth  is  especially  great. 

Another  mode  of  directlj'  transmitting  syphilis 
to  or  by  the  mouth  is  through  nursing,  viz.:  a  wet 
nurse  with  a  chancre  of  the  lip  or  tongue,  etc.,  may 
infect  the  child  or  a  heredosyphilitic  child  may  infect 
the  wet  nurse.  The  parts  in  and  about  the  mouth  are 
especially  exposed  to  the  indirect  transmission  of 
syphilis  through  the  general  use  of  eating  and  drink- 
ing utensils,  cigar  holders,  jjipes,  wind  musical  instru- 
ments, etc.,  for  the  treponema  pallidum  can  remain 
alive  outside  of  the  body  for  days  when  it  is  in  a 
moist  medium.  Among  the  large  number  of  isolated 
cases  of  primary  syphilis  of  the  mouth  where  the  way 
of  contracting  th^  disease  was  not  at  the  time  deter- 
mined, the  formerly  endemic  indirect  buccal  transmis- 
sion of  syphilis  among  glass-blowers  may  be  men- 
tioned, when  tubes  were  passed  from  one  worker  to 
the  other.  Surgical  and  dental  instruments  play  an 
important  role  in  the  indirect  transmission  of  syphi- 
lis, but  to-day  no  scientific  physician,  surgeon,  or 
dentist  would  use  an  instrument  which  had  not  been 
properly  sterilized. 

It  is  difficult  to  explain  the  comparative  frequency 
of  a  chancre  upon  the  tonsil.  The  tonsils  are  very 
much  less  subjected  to  trauma  than  either  the  lips, 
the  tongue  or  cheeks,  and  the  direct  transmission  of 
the  causal  agent,  from  mouth  to  mouth  and  thus  to 
tonsils,  or  by  touching  them  with  instruments,  etc.,  is 
certainly  very  seldom.    For  these  reasons  it  is  highly 

13 


probable  that  the  tonsils  are  prone  to  the  sj-philitic 
infection,  and  that  the  treponemata  pallida,  gaining 
entrance  to  the  mouth  either  directly  or  indirectl}% 
stick  to  the  tonsils  and  perhaps  remain  alive  there  for 
some  time  in  the  lacunc-e,  and  even  pass  through  the 
uninjured  mucous  membrane. 

The  prognosis  of  the  extragenital  chancre  has. 
been  considered  especially  unfavorable.  In  general 
this  is  not  correct.  Often  the  extragenital  chancre  is 
not  recognized,  and  early  treatment  is  thus  omitted 
which  favors  the  development  of  serious  lesions.  It 
has  been  asserted,  but  not  proved,  that  primary  le- 
sions upon  the  head  afford  the  easj'  transit  of  espe- 
cially great  numbers  of  treponemata  to  tlie  brain, 
and  thus  favor  the  occurrence  of  cerebral  manifesta- 
tions. 

Between  the  time  of  the  infection  and  the  occur- 
rence of  the  first  manifestation  or  the  initial  lesion, 
there  is  a  latent  period,  or  period  of  incubation,  of 
two,  three,  and  four  weeks. 

On  the  lips  the  chancre  appears  at  first  as  a  flat, 
not  shining  erosion  about  the  size  of  a  lentil,  which 
is  elevated  very  little  or  not  at  all  above  the  surface 
of  the  surrounding  mucous  membrane  {Chancrous 
erosion.  Fig.  1).  It  gives  a  distinctly  hard  (sclerosis 
or  induration)  cartilaginous  feel  to  the  touch  which, 
in  the  absence  of  other  syphilitic  manifestations,  is 
characteristic  of  syphilis.  The  erosion  has  no  cover- 
ing, especially  if  tlie  patient  has  licked  it  consider- 
ably, but  it  may  have  a  thin  fibrinous  membrane.  On 
pressure  there  exudes  from  the  surface  of  the  chancre 
an  abundant  clear  yellow  serum  in  which  numerous 
trej)onemata  pallida  are  easily  found.  This  small 
erosion  increases  in  size  until  it  may  have  a  diiunctcr 
of  2  centimetres.  The  iudnration  always  present  in 
this  form  of  chancre  is  slight  and  superficial.  This 
type  of  chancre  is  almost  always  ])ainlcss,  and  tiiis, 
accom])atiicd  by  the  fact  that  it  occasions  scarcely  any 
inconvenience  and  is  often  not  noticed  by  the  syphi- 

11 


Htic,  makes  him  a  menace  and  favors  the  spreading 
of  the  disease. 

Both  genital  and  extragenital  chancres  may  be 
either  the  erosive  type  or  a  papular,  elevated  or  even 
a  hjipcrirophicd  chancre  (Fig.  2).  We  have  then  a 
tumor  with  a  cartilaginouslike  hardness,  the  surface 
of  which  IS  either  entirely  covered  with  epithelium  or 
eroded.  It  may  be  covered  with  a  fibrinous  mem- 
brane, crusts  or  with  a  covering  resembling  bark. 
The  centre  of  the  primary  lesion  on  the  lip  often 
undergoes  suppm-ation,  so  that  an  ulcerated  chancre 
is  found  which  has  craterlike  edges,  an  uneven  base 
covered  with  a  milky  pellicle  and  pus,  or  pus  mixed 
with  blood  or  with  rupiallike  crusts  or  with  crusts 
resembling  oyster  shells. 

The  ulcer  is  surrounded  by  an  intensely  indurated 
tissue,  yet  the  induration  is  often  much  less  than  in 
non-ulcerated  lesions.  The  development  of  the  ul- 
cerated chancre  is  in  many  cases  the  result  of  a  mixed 
infection.  The  entire  lip  is  seldom  infiltrated,  yet 
when  the  lesion  is  situated  upon  the  ujjper  lip  there 
may  be  a  snoutlike  or  elephantiasic  thickening. 

The  lip  chancre,  as  well  as  an  initial  lesion  else- 
where, alwaj's  involves  the  neighboring  lymph  nodes 
or  ganglia,  so  that  an  adenopathy  of  the  submaxil- 
lary and  submental  lymph  ganglia  follows.  The 
lymph  nodes  are  swollen  and  a  lateral  position  of 
the  chancre  determines  a  unilateral  involvement. 

There  takes  place  unilateral  enlargement  of  sev- 
eral ganglia  determined  by  that  side,  on  the  right  or 
left  of  the  median  line,  of  the  lip  upon  which  the 
chancre  is  situated.  The  lymph  ganglia  or  nodes  are 
jjaijiless  and  are  freely  movable.  Occasionally, 
through  a  mixed  infection  (more  often  with  a  pri- 
mary lesion  of  the  buccal  cavity),  they  undergo  sup- 
puration, break  down  and  even  rupture  through  the 
skin.  The  suppuration  of  these  neighboring  lymph 
nodes  does  not,  however,  indicate  that  the  previous 
diagnosis  of  chancre  was  incorrect. 

15 


The  primary  lesion  on  the  lips  is  usually  single 
and  lias  a  predilection  for  the  middle  of  the  ver- 
milion, where  cracks,  fissures,  etc.,  are  most  often 
seen.  The  solitary  appearance  of  the  chancre  is  gen- 
erally a  peculiarity  of  the  syphilitic  infection  and  is 
explained  by  the  fact  that  a  chancre,  as  it  develops, 
confers  to  the  entire  body  and  especially  its  environs 
such  a  grade  of  immunity  that  it  is  difficult  to  pro- 
duce an  autoinoculation.  The  chancroid,  however, 
is  always  autoinoculable.  The  widely  prevalent  view 
that  the  cliancre  is  always  invariably  solitary  is  far 
from  being  correct,  for  by  simultaneous!}^  infecting 
several  points  it  is  possible  to  cause  the  development 
of  several  chancres  at  the  same  time  (Fig.  2) .  More 
than  one  initial  lesion  may  also  appear  if  the  auto- 
inoculation takes  place  at  a  very  early  period  in  the 
disease  before  sufficient  syphilitic  antibodies  are 
formed,  or  if  the  autoinoculation  is  very  intense,  e.g., 
on  an  opposing  surface  which  is  continually  coming 
in  contact  with  the  infectious  material.  Thus  it  is 
that  occasionally  on  a  point  on  the  upper  or  lower  lip 
corresponding  to  an  already  developed  chancre  we 
see  another  appear. 

On  the  tongue,  as  on  the  lip,  the  initial  lesion  may 
appear  as  an  erosion,  a  papular  erosion,  or  in  an 
ulcerated  form.  The  flat  chancrous  erosion  of  the 
tongue  can  appear  in  its  lightest  form  solely  as  a  flat, 
faintly  shining  spot  denuded  of  papilhc.  Induration 
is  only  determined  by  palpation.  In  most  cases  the 
infiltration  raises  the  primary  lesion  above  the  level 
of  the  tongue  (Fig.  3).  Tiie  erosion  is  not  coated 
with  anything,  there  is  no  pus,  nor  very  little  blood, 
but  on  i)rcssnre  a  clear  serum  exudes,  containing 
niiiiierous  spirocha'ta'. 

The  primary  lesion  can  develop  occasionally  in 
the  deeper  parts  of  the  tongue,  so  that  only  a  hard 
swelling  f)f  a  part  of  the  tongue,  e.g.,  the  tip  of  the 
tongue,  without  any  change  in  the  mucous  membrane, 
is  observed.     The  initial  lesion  of  the  tongue  rarely 

16 


causes  any  subjective  trouble.  The  disturbance  is 
purely  mechanical,  as  it  may  interfere  with  eating 
and  speaking.  The  ulcerated  primary  lesion  of  the 
tongue  is  very  rare.  It  can  lead  to  destruction  of  the 
tongue,  but,  as  a  rule,  it  does  not  spread  to  any  great 
extent.  There  is  little  pus,  and  the  ulcer  is  covered 
with  a  milky  pellicle.  The  tip  or  side  of  the  tongue 
is  the  seat  of  predilection  of  the  chancre,  and  the  sub- 
maxillary lymph  nodes  are  always  involved. 

On  the  gums,  cheeks,  and  palate  the  initial  lesion 
is  but  seldom  seen,  but  it  appears  oftener  upon  the 
tonsils. 

As  mentioned  above,  it  is  not  easy  to  explain  the 
infection  of  the  tonsils,  and  while  the  chancre  of  the 
lip  and  tongue  have  distinct  characteristics,  that  of 
the  tonsil  has  none.  It  may  appear  upon  the  tonsil 
in  the  erosive,  papular,  or  ulcerated  form,  but  the  in- 
duration is  not  especially  marked  and  the  whole 
process  is  more  diffuse,  less  sharply  marked  off  and 
therefore  not  so  easy  to  define.  The  diagnosis  is 
difficult.  Sometimes,  however,  the  tonsil  is  pale  and 
protrudes  markedly  and  exhibits  a  cartilaginous 
hardness,  which  can  be  proved  on  palpation.  From 
the  erosion  or  ulceration  of  the  surface  of  the  tonsil 
not  much  can  be  determined,  and  there  is  very  little 
congestion  of  the  surroimding  parts.  The  chancre 
of  the  tonsil  may  appear  as  a  tonsillitis,  with  great 
congestion  and  cedema  of  the  entire  throat.  With 
the  ulcerated  form  of  tonsillar  chancre  there  is  often 
a  marked  inflammatory  reaction.  The  ulceration, 
which  can  be  markedly  anfractuous,  is  covered  with 
pus  and  bleeds  more  profusely  than  any  other  form 
of  chancre. 

The  primary  lesion  of  the  tonsil  is  sometimes  diffi- 
cult to  diagnose  from  diphtheria,  carcinoma,  tubercu- 
losis of  the  tonsil,  or  a  severe  tonsillitis,  except  where 
the  tonsillitis  is  bilateral.  A  primary  lesion  of  the 
tonsil  can  occasion  considerable  uneasiness,  pain  and 
difficulty  in  swallowing.    It  produces  an  adenopathy 

17 


of  the  submaxillary  ganglia  and  the  ganglia  at  the 
angle  of  the  mandible. 

The  diagnosis  of  an  initial  lesion  upon  the  lip 
and  tongue  is  easy,  especially  if  its  course,  the  be- 
havior of  the  neighboring  lymph  nodes  and  other 
allied  conditions  are  considered.  The  small  chan- 
crous  erosion  may  escape  unobserved  or  be  regarded 
as  a  harmless  erosion.  Palpation  of  the  lesion,  how- 
ever, quickly  determines  its  specific  nature.  A  large 
elevated  papular  chancre  is  not  likely  to  be  con- 
fused with  any  other  lesion. 

At  times  secondary  manifestations,  a  mucous 
patch  or  ulceration,  can  be  mistaken  for  a  primary 
lesion.  It  is  very  difficult  to  differentiate  them,  even 
if  tliey  are  present  simultaneously.  The  presence  of 
treponemata  and  a  positive  Wassermann  reaction 
are  of  no  help  in  the  differential  diagnosis.  The 
conditions  of  the  h'mph  nodes  are  not  of  much  help, 
in  diagnosis,  when  both  a  chancre  of  the  lip  and 
mucous  patches  on  the  tongue  are  present  at  the  same 
time. 

The  chancre  may  be  but  slightly  indurated,  while 
there  is  considerable  infiltration  of  the  mucous  patch. 
At  times  a  differential  diagnosis  is  impossible.  A 
gumma  can  at  times  simulate  a  primary  lesion  and 
vice  versa.  I  But  the  adenopathy,  the  presence  of 
spirocha2ta2  in  the  lesion  and  other  symptoms  of  the 
disease  assist  in  the  diagnosis.  The  differential  diag- 
nosis of  carcinoma,  tuberculosis,  and  syphilis  will  be 
later  considered. 

The  confusing  of  the  chancre  with  any  other 
mouth  lesion  is  unlikely.  Furuncles  on  the  lip  last 
only  a  few  days,  are  very  painful,  soon  suppurate, 
an<l  are  often  accompanied  by  a  painful  adenitis. 
Tonsillar  abscess  and  catarrhal  or  ulcerated  angins 
run  a  different  course.  Tliere  is  a  febrile  onset,  great 
])ain  and  (Hllicully  in  swallowing,  and  they  are  usu- 
ally bilateral  and  heal  quicker.  IJut  it  must  not  be 
forgotten  that  an  initial  lesion  can  at  times  assume 

18 


the  aspect  of  a  unilateral  angina  and  may  be  accom- 
panied at  the  time  of  the  secondary  manifestations 
with  a  low  fever.  It  is  also  possible  to  mistake  a 
case  of  the  Plant-Vincent  angina  for  a  primary  le- 
sion (Fig.  41). 

The  chancroid  or  soft  chancre  is  rarely  found  in 
the  mouth,  and  when  it  does  appear  it  is  usually  by 
autoinocidation  of  a  lesion  somewhere  else  on  the 
body.  It  is  not  always  easy  to  distinguish  by  sight 
a  chancroid  from  an  ulcerated  chancre.  The  chan- 
croid, however,  is  distinguished  by  its  rapid  growth, 
absence  of  induration,  undermined  edges,  irregular 
base  with  pus  and  blood  exudating,  pain,  and  the 
neighboring  adenitis,  which  may  or  may  not  be  ac- 
companied by  a  suppurative  periadenitis;  and,  finally, 
the  presence  of  the  causal  agent,  viz.,  the  Ducrey- 
Krefting  Streptobacillus. 


19 


Secondary  Syphilis 

Four  to  six  weeks  after  the  occurrence  of  the  pri- 
mary lesion  the  secondary  manifestations  usually  oc- 
cur. Witii  their  appearance  the  secondary  period 
of  the  disease  begins.  The  causal  agent  of  the  dis- 
ease has  now  traversed  the  entire  body  by  way  of 
the  blood  and  lymph,  and  a  general  systemic  infec- 
tion of  the  organism  residts.  At  this  period  the 
syphilis  affects  all  the  organs  (even  the  viscera  and 
nervous  sj'^stem ) ,  and  particularly  the  skin  and 
dermo-j)apillary  mucous  membrane  (visible  mucous 
membranes),  which,  like  the  skin,  are  derived  from 
the  ectoderm  and  have  nearly  the  same  histological 
characteristics.  [Included  among  the  dermo-papil- 
lary  mucous  membranes  are  those  of  the  lips,  mouth, 
tongue,  pharynx,  larynx,  nose  and  eyelids. 

The  manifestations  upon  the  skin  and  the  mucous 
membranes  are  known  as  cutaneous  and  mucous 
syphilides;  the  latter  are  also  commonly  called  mu- 
cous patches.  Tlie  mucous  syphilides  are  moist  and 
usually  contahi  the  trcponcnia  pallidum  in  great 
numbers.  The  cutaneous  syphilides  are  dry  lesions. 
Mucous  patches  may  also  occur  upon  the  skin,  where, 
having  becoM:e  eroded  or  ulcerated,  they  are  known 
as  condylomata  lata.  Mucous  patches  are  absent  in 
mucous  membranes  of  entodermic  origin.  This  is  a 
striking  example  of  the  fact  that  syphilis  has  a  pre- 
dilection for  tissues  derived  from  certain  embryonal 
(ills.  The  ])athological  differences  in  the  mucous 
iiniiibranes,  derived  resj)ectively  from  the  ectoderm 
and  entoderm,  correspond  with  cmbryological  differ- 
entiation.— Tu.] 

20 


The  skin  eruption  or  exanthem  may  be  repre- 
sented in  varying  frequency  by  any  of  the  following 
types  of  syphilides,  viz. : 

1.  As  very  pale  rose-colored  spots  (erythema  or 
roseola),  which  are  usually  of  ephemeral  duration 
and  often  escape  detection  except  by  a  careful  ob- 
server. 

2.  The  roseola  may  be  more  intense;  last  longer, 
with  some  very  slight  infiltration. 

3.  Small  or  large  papules. 

4.  Small  or  large  pustules. 

5.  The  ulcerated  syphilide — the  larger  pustules 
forming  small  idcers,  which  leave  scars  on  healing. 

As  in  the  skin,  so  may  the  secondary  manifesta- 
tions appear  in  the  mucous  membrane.  With  the 
first  general  or  systemic  manifestation  of  the  disease 
lesions  of  the  mucous  membrane  of  the  mouth  are 
rarely  absent,  and  in  the  later  course  of  the  second- 
ary period  they  are  extremely  frequent. 

It  often  happens  that  after  the  eruption  has  dis- 
appeared, with  the  exception  of  the  mouth  lesions, 
there  are  no  syphilitic  manifestations.  These  mouth 
lesions  give  no,  or  at  times  extremely  little,  evidence 
of  their  presence,  and  as  they  are  particularly  in- 
fectious the  importance  of  recognizing  them  is  evi- 
dent. ^^Corresponding  to  the  time  of  the  appearance 
of  the  roseola,  simple  erythematous  spots  (Fig.  4) 
appear  upon  the  mucous  membrane  of  the  mouth. 
These  spots,  ofttimes  very  ephemeral,  may  be  large, 
small,  round,  oval,  or  not  infrequently  confluent. 
The  only  perceptible  change  in  that  part  of  the  mu- 
cous membrane  where  they  are  situated  is  the  hy- 
peremia. These  spots  can  be  regarded  as  symptoms 
of  syphilis,  only  through  the  fact  that  their  appear- 
ance is  sjTichronous  with  that  of  a  secondary  syphi- 
lide and  that  they  react  to  antisyphilitic  treatment. 

A  simple  hyper.Tmia  of  the  isthmus  of  the  fauces 
— resembling  an  angina — with  sharp  lines  of  demar- 

21 


cation  from  the  non-erythematous  mucous  membrane, 
is  sometimes  seen. 

By  far  the  most  frequently  occurring  type  of 
syphilis  of  the  mouth  is  the  erosive  syplnUde  (Fig. 
5),  which  is  a  round  or  oval  superficial  erosion  sel- 
dom larger  than  2  cm  in  diameter.  Its  surface  is 
faintly  shining,  very  little  roughened,  and  either 
slightly  redder  than  the  surrounding  mucous  mem- 
brane, above  which  it  is  rarely  raised,  or  a  slight 
glistening  gray.  There  is  a  sharp  line  of  demarca- 
tion between  the  lesion  and  the  healthy  mucous  mem- 
brane, and  inflammatory  reaction  is  usually  absent. 

If  inflammatory  reaction  takes  place  in  this  form 
of  syphilidc,  it  then  becomes  denser,  more  or  less 
raised  above  the  surrounding  mucous  membrane,  and 
can  be  detected  by  the  palpating  finger.  This  rep- 
resents the  true  "mucous  patch"  (Fig.  6) .  {Papcl  of 
the  Germans,  and  plaque  muqueuse  of  the  French.) 

The  surfaces  of  the  various  mucous  patches  differ 
greatly  in  appearance.  With  the  flat  form  we  have 
either  a  slight  erosion  of  the  mucous  membrane  or  a 
thin  yellow  fibrinous  coating,  or  the  epithelium,  re- 
maining intact  and  becoming  thicker  and  cloudy, 
gives  the  lesion  a  gray  appearance.  This  sometimes 
becomes  whitish,  yellowish  or  bluish,  somewhat  like 
an  oj)al,  and  hence  the  name  opaline  mucous  patch 
(Fig.  11)    (Plaques  Opalines). 

The  mucous  patch  may  become  raised  and  hyper- 
tropliicd  {ht/perfrophied  mucous  patch)  (Fig.  7), 
the  epithelium  usually  increasing  in  thickness.  The 
color  of  its  surface  is  a  more  pronounced  gray  or 
dirty  yellow  or  sometimes  distinctly  white  (Diph- 
theroid ) . 

\\  liilc  the  flat  mncons  patches  have  for  the  most 
part  a  smooth,  faintly  shining  surface,  the  hyi)er- 
tropliied  ones  are  rougli,  granular,  or  anfractuous. 
The  inflanmiatory  reaction  can  vary  greatly.  The 
imicoiis  patch  may  rise  precipitously  or  gradually 
from  the  normal  surrounding  mucous  membrane.    It 

22 


may  be  surrounded  by  a  slight  inflammatory  zone  of 
mucous  membrane,  or  it  may  be  situated  in  the  midst 
of  an  actively  congested,  inflamed  and  swollen  mem- 
brane. As  a  rule,  tlie  line  of  demarcation  between  the 
zone  of  inflammation  and  the  normal  membrane  is 
extremely  sharp. 

In  severe,  neglected  or  iintreated  cases  the  mu- 
cous patches  of  the  mouth,  as  of  the  skin,  may  often 
undergo  ulceration  {ulcerated  mucous  patcJies) 
(Figs.  8  and  9).  All  stages  are  met  with  from  that 
of  a  small,  superficial,  insignificant  ulcer  to  a  severe, 
inveterate,  idcerating  process,  with  extensive  de- 
struction of  the  submucous  tissue.  Neglected  oral 
hygiene,  smoking,  chewing,  surface  inequalities  of  the 
teeth,  or  a  badly  fitting  denture,  etc.,  play  a  promi- 
nent part  in  causing  these  ulcerated  mucous  patches. 
A  direct  mixed  infection  of  the  mucous  patch  will 
sometimes  cause  them. 

As  a  rule,  the  ulcers  appearing  during  the  sec- 
ondary period  of  syphilis  lie  in  an  acutely  inflamed 
area  and  are  surrounded  by  an  extensive  inflamma- 
tory zone.  They  may  be  round,  flat,  funnel-shaped, 
hollowed-out  or  irregular  in  form,  with  an  an- 
fractuous base  covered  with  pus  or  fibrin.  The  ul- 
cerated mucous  patches  can  give  rise  to  considerable 
pain,  particularly  if  they  are  situated  in  such  places 
as  are  exposed  to  mechanical  irritation.  It  is  com- 
paratively easy  to  find  the  treponema  pallidum  in 
the  erosive  and  hypertrophied  type  of  mucous  patch, 
while  in  the  ulcerated  form  it  is  often  very  difficult. 

True  serpiginous  ulcers  (healing  from  the  cen- 
tre) of  the  mucous  membrane  of  the  mouth  are  rare, 
yet  an  annular  syphilide  occasionally  ulcerates  and 
thus  simulates  a  serpiginous  ulceration  (Fig.  10). 

On  account  of  certain  histological  peculiarities  of 
the  tongue  (viz.,  the  poorly  developed  submucosa 
and  as  a  result  the  scarcely  movable  mucosa  on  the 
upper  surface  and  base  of  this  organ,  absence  of 
glands  in  the  mucosa  and  the  presence  of  epithelial 

23 


papillae  and  lymphoid  tissue),  the  aspect  of  syphi- 
lides  of  the  mucous  membrane  of  the  tongue  often 
differs  essentially  from  that  of  syphilides  of  the  mu- 
cous membrane  of  the  rest  of  the  mouth.  Sometimes 
the  papillfe  are  especially  pronounced,  and  then  the 
patches  stick  up  from  the  mucous  membrane  as 
rough  gray  spots.  Sometimes,  on  account  of  the 
syphilitic  inflammatory  process,  the  pajjilhT  have 
disappeared,  resulting  in  smooth  reddish  spots,  be- 
tween which  there  is  either  a  normal  or  coated  spot 
of  mucous  membrane  (alopecia  of  the  tongue).  If 
the  syphilitic  infiltrate  or  mucous  patch  attacks  an 
otherwise  normal  tongue,  except  that  it  has  deep  fur- 
rows, the  furrowing  becomes  especially  striking  in 
appearance  as  star  or  V-shaped  rhagades  (Fig.  13). 

Very  frequently  in  the  early  stages  of  secondary 
syphilis  a  deep  interstitial  inflammatory  process 
tends  to  involve  the  tongue,  especially  if  mucous 
patches,  more  often  idcerated  ones,  have  existed  for 
a  long  time  iipon  the  mucous  membrane  of  the  or- 
gan. Thus  early  in  the  disease  there  is  a  diffuse 
glossitis,  whicli  gradually  passes  into  a  chronic  con- 
dition (Fig.  12),  and  can  lead  to  permanent  changes 
in  the  tongue  [chronic  interstitial  glossitis,  or  scle- 
rosis of  the  tongue).  The  "smooth  atrophy"  of  the 
base  of  the  tongue,  which  has  for  some  time  been  con- 
sidered as  an  imjjortant  point  in  the  diagnosis  of 
syphilis,  is  caused  by  the  chronic  inflammation  of  the 
tongue. 

The  different  configurations  of  the  syphilides 
whicli  are  seen  upon  the  skin  may  be  encountered 
upon  the  mucous  membrane  of  the  mouth.  Most 
often  round  or  oval  foci  are  seen,  by  the  confluence 
of  whicli  Iiow-sliapcd  j)atchcs  arc  formed.  The  ex- 
tension of  each  individual  focus  is  usually  not  very 
great,  but  with  the  hypertrophic  types  may  be  quite 
extensive.  The  pronounced  ring  or  garland  form  of 
syphilidc — the  so-called  orbicular,  annular  or  cir- 
cinatr  s//philide  (Figs.  10  and  17)— is  not  often  seen 

24 


in  the  mouth.     The  favorite  seat  for  the  circinate 
syphilide  is  about  the  lips  (Fig.  20). 

The  syphilis  of  the  isthmus  of  the  fauces,  or  so- 
called  syplnlitic  angina  {Angina  si/philitica.  Syphi- 
litic sore  throat),  is  the  most  frequent  appearing 
form  of  mouth  syphilis  seen  in  the  secondary  period 
of  this  disease.  It  differs  in  appearance  according 
to  the  situation  and  kind  and  intensity  of  the  con- 
gestion. The  tonsils  are  not  always  involved.  The 
condition  and  size  of  the  tonsils  may  remain  normal, 
and  they  may  even  disappear  between  the  thickened 
pillars  of  the  fauces  or  they  may  be  so  congested, 
swollen  and  inflamed  that  they  nearly  come  in  con- 
tact and  almost  occlude  the  fauces.  Cases  where  the 
tonsils  alone  are  involved  are  rare.  Mucous  patches 
in  the  form  of  plugs  can  lie  directly  in  the  openings 
of  the  follicles,  so  that  the  appearance  of  the  tonsils 
resembles  that  of  a  follicular  tonsillitis.  These  iso- 
lated mucous  patches  soon  run  together,  and  the 
process  almost  always  tends  to  extend  and  involve 
the  pillars  of  the  fauces.  It  is  this  localization  of 
this  lesion  upon  the  faucial  pillars  which  distin- 
guishes the  syphilitic  from  the  follicular  angina  or 
ordinary  follicular  tonsillitis.  Very  often  a  patch  is 
seen  on  the  edge  of  the  anterior  pillars  of  the  fauces 
which  extends  backward  and  involves  the  tonsils  or 
upward  and  forward  in  an  arched  manner  until  it 
even  involves  part  of  the  hard  palate.  Sometimes  a 
mucous  patch  is  found  in  the  pocket  between  the  ton- 
sil and  the  anterior  pillar  of  the  fauces,  and  thus  be 
confined  entirely  to  the  posterior  surface  of  the  pil- 
lar or  appear  as  a  small  projecting  point,  or  it  may 
become  apparent  only  when  the  pillar  is  lifted  off 
from  the  tonsil  with  an  instrument.  The  patches 
can  appear  as  isolated  small  foci,  which  may  be  few 
or  many,  or  they  can  become  confluent  and  quickly 
involve  other  parts  by  peripheral  extension.  In  the 
mildest  form  of  angina  the  mucous  membrane  is  only 
a  little  thickened  and  has  a  soft,  grayish  tone,  as  if 

25 


it  were  covered  over  with  milk  or  been  painted  with 
a  sohition  of  silver  nitrate  (Figs.  15  and  16). 

In  niucous  patches  which  have  undergone  hyper- 
trophy and  considerable  infiltration,  the  color  be- 
comes markedly  yellow  or  distinctly  white  (Fig.  18). 
In  sucli  a  case  the  syphilitic  angina  resembles  diph- 
theria, esjDecially  if  the  surrounding  mucous  mem-> 
brane  is  congested,  oedematous,  and  intensely  in- 
flamed, which  often  happens  to  the  loose  submucous 
tissue  of  the  soft  palate  and  u\iila. 

Small  flat  lesions  of  the  mucous  membrane  with 
a  grayish  papular  border  are  quite  frequent.  They 
have  a  predilection  for  the  free  borders  of  the  soft 
palate,  which  has  thereby  an  eaten-out  apj)earance. 
Large  hypertrophied  mucous  patches  of  long  stand- 
ing, which  are  inclined  to  form  small  central  ulcera- 
tions, togetlier  with  large  bow-shaped  lesions,  may 
appear.  Finally,  there  sometimes  develops  on  the 
fauces  large,  deeply  penetrating  ulcerations  of  the 
submucous  tissue,  which  may  lead  to  the  formation  of 
scars  (Fig.  19). 

The  multiplicity  of  syphilitic  manifestations 
upon  the  mucous  membrane  of  the  mouth  during  the 
secondary  period  of  the  disease  make  their  diagnosis 
particularly  difficult.  Naturally,  there  are  cases  where 
the  experienced  physician  does  not  doubt  for  a 
moment  that  he  is  dealing  with  a  case  of  syphilis; 
nevertlieless,  he  should  always  act  with  the  greatest 
caution,  and  search  for  every  possible  aid  in  diag- 
nosis, lie  should  examine  the  entire  body  for  evi- 
dences of  the  disease.  As  already  stated,  a  seat  of 
predilection  of  secondary  syphilides  (circinate)  is  on 
the  skin  surrounding  the  mouth  (Fig.  20).  With 
subjects  having  especially  well-developed  sebaceous 
glands  infiltration  of  the  nasolabial  folds  may  de- 
velop, which  often  appears  either  as  a  disfigurement 
of  a  dull  bluish-red  color  or  as  a  light  infiltrate  or 
as  a  more  or  less  thickened  mucous  patch — Cnndif- 
loma  Latum  (Fig.  .'5).    The  furrow  between  the  chin 

26 


and  lower  lip,  which  contains  numerous  sebaceous 
glands,  is  also  often  the  seat  of  mucous  patches. 

The  consideration  of  the  anamnesis,  the  observa- 
tion of  the  course  of  the  disease,  the  influence  of 
treatment  and  the  result  of  the  Wassermann  reaction 
help  in  confirming  a  diagnosis.  While  the  final  and 
most  important  evidence  of  the  disease  is  the  pres- 
ence of  the  treponema  pallidum  in  the  lesion. 


27 


I 


Tertiary  Syphilis 

The  syphilitic  lesions  in  the  mouth  accompany- 
ing the  tertiary  period  of  the  disease  are  frequent,  but 
have  no  such  predilection  for  this  cavity  as  have  the 
secondary  manifestations.  The  lips,  tongue,  hard 
and  soft  palate,  the  tonsils  as  well  as  the  bones  form- 
ing the  mouth  can  all  be  attacked.  Doubtless  the 
injuries,  irritations,  etc.,  to  which  the  mouth  is  con- 
tinually subjected  can  act  as  they  did  for  the  sec- 
ondary lesions  as  stimuli  for  the  production  of  the 
tertiary. 

Tertiary  syphilis  in  the  mouth,  as  in  the  skin, 
appears  in  many  forms.  Lesions  occur  in  the  mouth 
as  papules,  and  as  small  or  large  nodules.  These 
may  form  numerous  small,  flat,  and  often  reticulated 
ulcers  (Fig.  21),  which  gradually  extend  over  a  con- 
siderable surface.  Sometimes  they  heal  from  the  cen- 
tre and  sometimes  otherwise.  These  nodules,  in- 
stead of  undergoing  a  necrobiosis  and  forming  ulcers, 
can  become  sclerosed  and  cause  the  formation  of  flat, 
reticulated  cicatrices — tertiary  papular  sifphiUde. 
Tertiary  sypliilis  of  the  mouth  appears  chiefly  in  the 
form  of  this  tertiary  papular  syi^hilide,  if  the  process 
starts  in  the  mucous  membrane. 

More  often  the  tertiary  sy])hilitic  process  begins 
in  the  submucous  tissue,  leading  to  the  formation  of 
giimmata,  which  undergo  a  more  or  less  rapid  de- 
velopment and  necrobiosis. 

In  general,  the  syphilitic  neoplasms  in  the  mouth 
show  no  special  tendency  to  extend.  Yet,  like  gum- 
matous processes  of  the  skin,  those  of  tlie  lips, 
tongue,   and   especially  about  the   soft  palate   and 

28 


fauces,  may  become  large  tumors,  which  quickly  un- 
dergo necrosis  and  form  extensive  ulcers.  These 
ulcers,  embedded  in  a  firmly  infiltrated  area,  have 
irregular  or  arched  borders,  and  often  undermine  the 
inflamed  congested  mucous  membrane  and  thus  ex- 
tend to  appear  at  the  surface  at  some  distant  point. 
The  floor  of  the  ulcer  is  very  uneven,  bleeds  easily, 
and  is  covered  with  pus  or  a  viscid  non-offensive 
smelling  serous  exudate.  The  gumma,  as  a  rule,  is 
painless,  and  especially  characteristic  is  its  rapid  de- 
velopment, its  continuous  marked  tendency  to  extend 
and  to  involve  in  the  coagulation  necrosis  process, 
all  tissues  within  reach.  This  is  especially  true  of 
gummatous  ulcers  originating  in  the  musculature  of 
the  soft  palate,  which  often  in  a  short  time  bring 
about  considerable  destruction.  In  a  few  days  ne- 
crosis and  perforation  of  the  entire  soft  palate  and 
uvula  may  take  place.  The  ulcer  may  even  extend 
to  the  posterior  pharyngeal  wall  and  the  naso- 
pharynx. With  such  a  lesion  of  the  soft  palate  there 
is  usually  an  accompanying  acute  inflammatory 
process,  congestion  and  cedema. 

The  gummatous  processes  in  the  lips  and  tongue 
run  a  less  violent  course,  as  the  tissues  are  denser,  so 
there  is  a  correspondingly  slower  development  and 
necrosis  of  the  gumma  and  a  less  active  inflammatory 
reaction.  In  these  localities  the  opportunity  is  af- 
forded to  observe  the  gradual  growth  of  the  gumma- 
tous nodes,  their  central  softening  and  rupture. 

The  tertiary  syphilitic  processes  of  the  mouth 
often  have  their  origin  in  the  underlying  bone  or 
periosteum.  The  mandible,  or,  as  more  often  occurs, 
the  hard  palate  or  bones  of  the  nose,  may  be  involved. 
The  destruction  of  the  periosteum  leads  without  ex- 
ception to  a  necrosis  of  the  bone  to  which  it  was  at- 
tached. As  this  process  of  destruction  is  not  pain- 
ful, and  as  it  frequently  takes  place  in  parts  which 
cannot  be  easily  seen,  it  often  happens  that  various- 
sized  pieces  of  necrotic  bone  are  discharged  before 

29 


the  patient  is  aware  that  anything  is  the  matter.  The 
first  symptom  is  redness  and  a  sHght  doughy  swell- 
ing of  the  mucous  membrane,  then  at  a  circumscribed 
spot  a  pustule  forms,  and  from  this  there  later  exudes 
a  creamy,  viscid  pus.  The  rough  surfaces  of  the  de- 
nuded bones  can  be  easily  detected  by  a  probe,  and  if 
an  immediate,  energetic  treatment  is  not  afforded,  a 
large  ulcer,  followed  by  sequestra,  quickly  develops, 
which  leads  to  inoperable  bony  defects  and  perfora- 
tion of  the  hard  palate  (Fig.  22).  In  cases  which 
are  severe  and  extensive  the  entire  palate  and  all  the 
nasal  bones  may  be  destroyed,  so  that  the  oral  and 
nasal  cavities  become  one.  Even  if  the  gummatous 
inflammatory  process  is  limited  in  its  destruction  and 
healing  takes  place,  characteristic  defects  and  cica- 
trices result. 

The  healing  of  a  gimimatous  ulcer  in  soft  tissue 
results  in  peculiar  radiating  cicatrices,  which 
strangely  distort  the  non-involved  tissue.  Juxta-im- 
posed  ulcerated  surfaces  may  become  united. 

Tiie  soft  palate  may  be  united  to  the  posterior 
pharyngeal  wall  (Fig.  23),  while  respiration  is  ef- 
fected through  a  perforation  in  the  palate.  Small 
perforations  of  the  hard  or  soft  palate  may  close 
spontaneously,  while  the  larger  remain  open  and 
cause  disturbances  in  speaking  and  eating  until  they 
are  closed  either  by  ojjeration  or  prosthesis. 

Aside  from  the  papular,  gummatous,  and  ulcer- 
ated tertiary  processes  in  the  mouth,  wliicli  are  only 
distinguished  from  those  of  the  skin  by  their  posi- 
tion and  not  l)y  their  behavior,  there  may  appear 
other  tertiary  syphilitic  manifestations  which  have 
more  the  diaracter  of  visceral  sy|)hilis.  Instead  of 
the  syphilitic  neoplasm  undergouig  sclerosis  or  ne- 
crobiosis and  thereby  becoming  a  gumma,  the  two 
processes  may  combine,  forming  a  sclcrogummatous 
tissue.  This  is  the  usual  type  of  sy])hilitic  neoj)lasia 
found  in  tlic  interstitial  tissue  of  the  viscera. 

The  lips,  which  are  seldom  involved  in  this  man- 


ncr,  are  thickened,  infiltrated,  and  tibrons.  Some- 
times they  are  covered  with  superficial  ulcerations. 
They  have  an  elephantiasic  or  snoutlike  appearance. 
[This  hypertrophic  syphiloma  of  the  lips  is  some- 
times called  si/philitic  Icoutitisis. — Tk.] 

Interstitial  tertiary  syphilitic  lesions  of  the 
tongue  are  comparatively  frequent.  As  the  infiltrate 
is  superficial  or  deep,  so  is  a  single  part  or  the  entire 
tongue  affected;  thus  producing  different  clinical 
pictures. 

With  a  diffuse  infiltration  the  entire  tongue  as- 
sumes a  jDecidiar  dense,  rigid  condition.  It  feels 
hard;  cannot  be  moved;  its  surface  has  a  faint  lustre; 
radiating  furrows  traverse  the  organ,  and  the  papilla? 
have  disappeared  {Sclerosis  of  the  Tongue) .  ]More 
often  the  added  retraction  and  atrophy  of  the  infil- 
tration lead  to  a  lobulated  condition  of  the  surface 
[Lingua  Lohata). 

With  a  superficial  infiltration  the  lobes  are  small- 
er and  the  furrows  shallower.  Deeper  j)rocesses  may 
lead  to  deeper  furrows,  to  the  formation  of  large  lobes 
and  to  an  appearance  of  the  tongue  as  if  a  part  of 
it  has  been  ligated.  The  mucous  membrane  in  such 
conditions  show  no,  or  scarcely  any,  change. 

The  sclerosis  of  the  tongue  and  the  consecutive 
atrophy  both  in  the  superficial  and  deeper  part  can  be 
either  diffuse  or  circumscribed.  When  the  sclerosis 
is  peripherally  situated,  the  tongue  assumes  a  crum- 
pled-up,  serrated  form,  and  when  central,  a  more  or 
less  concave  appearance. 

The  sclerosed  areas  may  occasionally  become  ul- 
cerated, especially  if  the  sharp  edge  of  a  tooth  injured 
the  furrows  of  the  tongue  or  when  the  tongue  is 
subject  to  some  other  form  of  injury.  These  ulcer- 
ations, which  are  to  be  distinguished  from  ulcerated 
gummata,  if  they  persist,  may  sometimes  become 
carcinomatous.  These  deep  lesions  of  the  tongue 
come  to  the  physician  when  the  retraction  and 
atrophy  have  already  set  in.    They  are  extremely  re- 

31 


bellioiis  to  treatment,  and  in  this  and  through  their 
extremely  slow  development  they  distinguish  them- 
selves from  true  gmnmatous  processes. 

The  striking  fact  that  severe  and  extensive  ter- 
tiary syphilitic  lesions — neoplasms  and  ulcerations — 
never  involve  the  adjacent  lymph  ganglia,  is  a  most 
important  diagnostic  point. 

The  mouth  manifestations  of  malignant  syphilis 
are  worthy  of  especial  mention.  It  is  not  clear  under 
what  conditions  this  form  of  syphilis  makes  its  ap- 
pearance and  a  discussion  of  this  subject  cannot  be 
taken  up  in  this  work.  Alcoholism,  a  depraved  gen- 
eral nutrition  or  some  cachexia  may  act  as  predis- 
posing factors.  These  factors  surely  do  not  apply 
in  every  case.  In  a  number  of  cases  of  syphilis  soon 
after  the  infection,  the  disease  appears  in  a  form 
which  differs  entirely  from  the  clinical  picture  as 
usually  seen  in  the  secondary  period  of  syphilis. 
Either  the  lesions  are  of  a  very  grave  character  or 
there  is  a  marked  resistance  on  the  part  of  the  disease 
to  treatment. 

In  malignant  syphilis  exceptionallj'^  severe  ulcers 
of  the  skin  and  mucous  membranes  appear  even 
when  the  disease  has  not  reached  the  tertiary  period 
with  its  characteristic  gummatous  neoplasia.  These 
ulcers  extend  rapidly  with  great  resulting  destruc- 
tion, not  only  deeply,  but  also  over  the  surface  of 
the  body. 

These  ulcerations  of  malignant  syphilis  are  simi- 
lar to  those  observed  in  tertiary  syphilis  in  respect  to 
their  extent  and  the  destruction  caused  by  them. 

Through  the  confluence  of  neighboring  lesions 
(shaped  like  the  figure  8),  large  ulcers  are  formed 
which  lilecd  easily,  and  tlieir  walls  slope  precipitously. 
The  floor  of  the  skin  ulcers  is,  as  a  rule,  light  red, 
while  tliat  of  the  ulcers  involving  the  mucous  mem- 
brane usually  has  a  very  adherent  yellowish-gray 
coating.  In  the  mouth  these  malignant  ulcers  appear 
by  predilection  upon  the  soft  palate.    Here  extensive 

32 


inoperable  defects  can  be  produced  in  a  feAv  days, 
either  by  the  entire  destruction  of  the  velum  palati 
or  of  the  uvula  or  perforation  of  the  soft  palate  (Figs. 
24  and  25).  Destruction  of  bone  occurs  more  fre- 
quently with  malignant  than  with  tertiary  syphilis, 
and  the  destructive  process,  which  can  scarcely  be 
distinguished  from  the  manifestations  of  tertiary 
syphilis,  begins  either  in  the  periosteum  or  the  bone 
itself.  Malignant  syphilis  runs  a  more  rapid  course 
than  tertiary  syphilis,  so  rapid  that  it  never  takes 
the  form  of  a  gununatous  neoplasm.  It  appears,  in 
contradistinction  to  tertiary  syphilis,  in  various  situa- 
tions: thus,  bone  lesions  in  different  parts  of  the 
body  occur  synchronously  with  skin  and  mucous 
membrane  manifestations.  The  skin  lesion  has  partly 
the  character  of  a  papular  syphilide  of  the  secondary 
period  and  partly  that  of  the  tertiary  syphilitic  ulcer. 
The  hard  palate  is  sometimes  destroyed  in  cases  of 
malignant  lues.  Usually  the  perforation  of  the  pal- 
ate is  concomitant  with  the  destruction  of  the  bones 
of  the  nose. 


33 


Heredosyphilis 

Heredosyphilis  and  acquired  syphilis  are  identical. 
The  infection  in  the  former,  however,  takes  place  in 
utero  by  the  mother.  The  treponema  pallidum  is 
transferred  exclusively  via  the  placenta  to  the  embryo 
or  foetus. 

The  syphilitic  child  does  not  always  show  obvious 
symptoms  of  the  disease  at  birth.  They  can  develop 
later.  The  lesions  of  heredosyphilis  and  those  of  ac- 
quired secondary  syphilis  are  essentially  the  same,  but 
their  nature  and  the  localities  where  they  are  found 
in  the  child  and  adults  bodies  are  not  so,  as  the 
child's  organization  differs  from  that  of  the  adult. 
The  metabolism  and  circulation  of  the  blood  of  the 
foetus  differ  from  the  metabolism  and  circulation  in 
a  child  or  adult.  In  the  foetus  tlie  special  functional 
activity  of  certain  organs  and  the  rapid  growth  and 
development  of  tissues  cause  an  increased  blood  sup- 
ply to  given  regions  and  bring  about  local  conditions 
which  will  perhaps  later  on  permit  of  a  reaction  of 
certain  tissues  of  the  body  to  special  kinds  of  exter- 
nal stimuli  and  injury.  Where  these  regions  and  con- 
ditions are,  there  the  treponema  pallidum  lodges.  In 
utero  the  skin  and  mucous  membrane  are  not  vigor- 
ously attacked  by  tlie  treponema  pallidum,  altliough 
it  has  a  predilection  for  these  organs.  The  foetal 
syphilis  involves  however  the  liver,  spleen,  lung,  epi- 
physes of  joints,  etc.,  but  not  the  skin  and  mucous 
nicmbranes;  l)ecause  they  are  not  subjected  to  any 
special  irritation  in  utero.  After  birth,  on  account  of 
the  different  forms  of  injury,  irritation,  etc.,  mucous 
and  cutaneous  lesions  appear  and  on  account  of  the 

34 


weak  or  slip^ht  reactive  powers  of  the  tissues  they  are 
particuhirly  intense. 

Mucous  patches  are  found  in  the  mouth  upon  the 
mucous  membrane  covering  the  bones,  gums,  cheeks 
and  tongue,  upon  the  hps  and  especially  about  the 
angles  of  the  mouth.  In  the  two  latter  situations  they 
are  frequently  hypertrophied,  so  that  the  lips  become 
infiltrated  and  the  mucous  patches  on  the  lips  and 
about  the  angles  of  the  mouth  cracked,  ulcerated  and 
painful  by  the  more  or  less  continuous  crying  of  the 
child.  When  these  lesions  heal,  scars  remain  through 
life  as  stigmata  of  hereditary  sypliilis. 

The  diagnosis  of  syphilitic  lesions  in  the  mouth 
(Figs.  26  and  27)  of  the  newborn  is  not  always  easy. 
The  characteristic  mucous  patch  declares  itself  as  a 
slightly  hypertrophied  portion  of  the  mucous  mem- 
brane with  a  whitish  surface,  surrounded  by  an  ery- 
thematous areolar.  These  lesions  often  lose  their 
characteristic  appearance  quite  early,  and  in  cases 
where  they  become  eroded,  soft,  and  possibly  ulcer- 
ated, and  the  treponema  pallidum  cannot  be  found, 
a  guarded  diagnosis  must  be  made.  However,  the 
earliest  and  most  constant  symptom  of  heredosyphilis 
is  coryza  and  the  treponema  pallidum  while  easily 
found  in  the  serous  discharge  is  more  difficult  to  find 
in  the  later  purulent  and  bloody  discharge. 

Aside  from  the  clinical  manifestations,  the  follow- 
ing points  must  naturally  be  taken  into  consideration 
in  the  diagnosis  of  syphilis,  viz.:  The  history  of  the 
case  and  family  should  be  studied.  Have  the  father, 
mother,  sisters  or  brothers  ever  had  syphilis?  How 
often,  if  ever,  has  the  mother  aborted?  How  many 
children  in  the  family  have  died?  Have  any  of  the 
children  had  snuffles  or  an  eruption  soon  after  birth? 
Did  any  of  the  children  become  blind  in  early  life  or 
have  difficulty  in  hearing  at  that  time?  Is  the  Was- 
sermann  reaction  positive  not  only  of  the  child  but 
also  of  the  father  and  mother? 

The   differential    diagnosis    of   mucous   patches, 

35 


syphilitic  ulcerations  and  other  mouth  lesions,  diph- 
theria, parasitic  stomatitis,  etc.,  will  be  considered 
later. 

Hereditary  as  well  as  acquired  syphilis  may  have 
a  tertiary  period  in  which  the  lesions  are  not  only  the 
same  but  follow  the  same  course.  The  lesions  of  Late 
HercdosypJiilis  (Lues  Hereditaria  Tarda)  in  the 
mouth,  etc.,  consist  of  sclerotic  and  necrotic  gum- 
matous infiltrations  of  the  tongue,  lips,  hard  and  soft 
palate,  and  nose,  whicli  may  lead  to  destruction  of  the 
soft  palate  and  cartilages  of  the  nose  and  perforation 
of  the  hard  palate  (Figs.  28  and  29). 

These  late  manifestations  of  syphilis  usually  ap- 
pear a  number  of  years  after  (3  to  20  years)  birth, 
and  sometimes  they  are  the  only  symptoms  of  heredo- 
syphilis  observed. 

The  severe,  intrauterine  infection  of  the  foetus 
has  naturally  a  marked  influence  upon  its  develop- 
ment, so  that  aside  from  the  manifest  lesions  of  syph- 
ilis and  their  direct  local  sequels  the  heredosyphilitic 
child  shows,  as  a  rule,  the  evidences  of  a  severely  per- 
verted metabolism  in  a  blighted  development  or  so- 
called  developmental  hi/poplasia. 

In  the  course  of  time  this  general  hypoplasia  may 
be  overcome,  but  it  always  leaves  its  mark,  and  thus 
there  remains  with  these  heredosyphilitics  a  number 
of  permanent  changes  in  the  organism  which  are 
partly  the  secjuence  of  the  local  syphilitic  process  and 
partly  the  result  of  the  severe  damage  inflicted  upon 
the  entire  organism.  The  stigmata  uj)on  the  teeth 
may  be  classed  as  one  of  the  results  of  the  damage 
to  the  entire  organism,  and  in  order  to  understand 
these  it  is  necessary  to  know  something  of  the  process 
of  calcification  of  the  teeth  (Fig.  73). 

If  the  tooth  is  completely  developed  (calcification 
completed)  naturally  no  systemic  disease  can  alter  its 
slnicfMre.  If,  however,  the  dental-germ  is  injured 
before  the  period  of  calcification  is  completed,  it  may 
lead  to  a  substantial  disturbance  in  the  normal  pro- 

36 


cess  of  calcification  and  thus  to  a  deformity  of  the 
tooth. 

The  formation  of  dentin  begins  at  the  apex  of  the 
dentinal  papilla  and  extends  during  the  course  of 
several  months  to  its  base.  This  process,  begun  before 
birth,  continues  for  some  time.  The  formation  of 
the  dentin  cap  does  not  appear  in  all  teeth  at  the  same 
time.  In  deciduous  teeth  it  begins  in  the  5th  month 
of  foetal  life,  and  in  the  six-year  molar  in  the  6th  or 
7th  month  of  foetal  life.  At  birth  the  development 
of  the  dentin  for  the  deciduous  teeth  is  finished.  Of 
the  permanent  teeth  at  birth  only  the  6-year  molar 
has  a  dentin  cap. 

The  dentin  cap  appears  for  the  incisor  teeth  dur- 
ing the  first  and  second  months  after  birth. 

Later,  in  the  course  of  the  first  year  of  life,  the 
dentin  cap  appears  for  the  cuspids  and  still  later  for 
the  bicuspids. 

The  dentin  cap  for  the  2d  molars  begins  in  the 
third  year  and  for  the  last  molars  in  the  twelfth 
year. 

One  is  thus  able,  by  studying  the  changes  in  the 
crown  of  a  tooth  to  determine  with  considerable  ex- 
actness at  what  time  damage  was  done  the  tooth  germ. 
Deformities  of  the  deciduous  incisor  teeth  indicate 
some  disturbance  during  the  first  months  of  fcetal 
life. 

Degenerative  changes  of  the  morsal  surface  of 
a  six-year  molar  prove  the  presence  of  disturbances 
in  the  tooth  germ  shortly  before  birth,  and  on  the 
morsal  margin  of  the  incisor  teeth  during  the  first 
year  after  birth.  If  the  morsal  margin  of  a  tooth  is 
normal  and  the  deformity  is  on  the  crown  nearer  the 
gingival  margin,  then  the  time  when  the  disturbance 
affected  the  tooth  is  still  later.  As  extensive  as  the 
changes  are  along  tlie  tootli  extending  from  its  morsal 
to  its  gingival  margin,  by  just  so  long  a  time  has  the 
damaging  process  lasted.     Injury  with  repeated  re- 

37 


missions  leads  to  parallel  changes  on  different  levels 
or  heights,  along  the  surface  of  the  crown. 

It  is  higlily  probable  that  the  hypoplasia  of  the 
teeth  in  heredosyphilis  is  not  of  a  specific  nature — 
caused  by  the  syphilis  itself — but  is  a  sequela  of  the 
grave  systemic  disease  of  the  foetus. 

This  is  shown  by  the  fact  that  the  alterations  in 
the  teeth  appear  symmetrically,  always  involving  the 
teeth  of  the  same  period  of  calcification,  exactly  at 
the  same  time  and  to  the  same  extent.  If  the  disturb- 
ance was  the  sequence  of  a  local  syphilitic  process  in 
the  tooth  germ  or  in  its  neighborhood,  then  the  hypo- 
plasia would  appear  in.  an  unsymmetrical  manner, 
involving  teeth  of  different  periods  of  calcification. 

The  occasional  finding  of  the  treponema  palli- 
dum in  the  tooth  germ  of  a  heredosyphilitic  foetus 
does  not  seem  to  alter  this  view. 

It  is  possible,  however,  but  not  proved,  that  the 
hypoplasia  of  the  teeth,  as  well  as  that  in  the  epi- 
physes of  bones  may  be  caused  by  the  specific  systemic 
infection. 

The  evidence  that  the  defective  calcification  is  due 
to  syphilis  is  found  in  the  fact  that  the  developmental 
hypoplasia  begins  before  birth,  and  in  the  fact  that 
syphilis  is  the  only  disease  of  a  grave  and  continuous 
character  which  attacks  the  foetus  before  birth  or 
even  in  the  earliest  months  after  birth  and  leads  to 
such  a  marked  disturbance  in  the  general  metabolism. 
It  is  well  known  that  syphilis  is  the  only  known  intra- 
uterine infectious  disease.  Of  course,  occasionally,  a 
grave  disease  of  the  mother,  e.g.,  typhoid  fever  can 
cause  death  of  the  foetus  and  abortion.  In  the  pathol- 
ogy of  pregnancy  intrauterine  syphilis  appears  as 
tlic  chief  cause  of  abortion.  Acute  infectious  diseases 
or  chronic  disease  of  the  mother  as  tuberculosis,  and 
alcoholism  will  naturally  influence  the  nutrition  and 
development  of  the  foetus.  But  experience  teaches 
that  these  secondary  indirect  injuries  to  the  fa'tus 
<lo  not  so  interfere  with  its  development    as  to  lead 

38 


to  hypoplasia.  Tuberculosis,  rachitis  and  other  grave 
diseases  do  not  usually  exist  in  the  child  at  birth  and 
infectious  diseases  generally  come  later.  Kven  the 
gastroenteritis  occurring  during  the  first  months  after 
birth  does  not  occasion  such  devastation  that  one  can 
attribute  any  developmental  hypoplasia  to  it.  De- 
formed teeth  have  not  been  observed  in  children  who 
have  suffered  from  gastroenteritis. 

Some  months  after  birth  in  addition  to  syphilis 
other  diseases,  especially  rachitis  and  tuberculosis  can 
doubtless  affect  the  calcification  of  the  teeth  but  their 
stigmata  correspond  to  the  time  when  the  damage  is 
done  and  they  are  found  in  other  places  on  the  teeth. 
The  development  of  the  enamel  on  the  morsal  surfaces 
of  the  croviis  of  the  first  molar,  incisor  and  cuspid 
teeth  is  not  affected,  but  hypoplasia  may  be  seen  any- 
where on  the  surface  of  the  crown  of  the  teeth  extend- 
ing from  just  above  their  morsal  to  their  gingival 
margin.  Traces  of  injury  through  syphilis  can  be 
seen  at  these  points,  but  we  cannot  distinguish  them 
from  those  due  to  rachitis,  etc.,  as  they  are  not  at  all 
characteristic. 

The  view  that  anomalies  in  tooth  structure  are 
due  to  syphilis  is  supported  by  the  fact  that  other 
traces  of  heredosyphilis  are  often  seen  with  them, 
such  as  deformities,  swellings  on  bones,  saddle  nose, 
radiating  scars  about  the  mouth,  difficulty  in  hearing, 
a  positive  Wassermann  reaction;  or  in  a  case  of  ac- 
tive late  heredosyphilis,  a  tumor  on  a  bone  or  in  the 
pharynx  or  an  interstitial  keratitis. 

Usually  an  interstitial  keratitis  and  otitis  are  com- 
bined with  the  deformed  teeth,  constituting  the  Hut- 
chinson triad,  which  is  an  important  symptom  in  the 
diagnosis  of  heredosyphilis.  Here  the  positive  Was- 
sermann reaction  is  also  an  important  adjunct  in 
diagnosis.  The  stigmata  of  course  will  still  persist 
even  if  the  disease  has  long  since  run  its  course  and 
the  Wassermann  reaction  has  become  negative.  Oc- 
casionally, while  seeking  a  trace  of  syphilis  by  the 

39 


Wassermann  reaction,  the  reaction  proving  positive, 
the  teeth  were  examined  and  characteristic  defects 
were  discovered  on  them.  The  positive  Wassermann 
reaction  of  the  blood  of  the  father  and  mother  has 
been  supported  by  finding  tooth  hypoplasia  in  the 
mouth  of  their  child. 

The  more  carefully  the  cases  are  studied  so  nuich 
more  often  is  syphilis  seen  as  the  etiological  factor 
of  developmental  hypoplasia  of  the  teeth,  and  even 
if  the  proof  is  lacking  in  some  cases  (and  we  cannot 
deny  that  occasionally  another  cause  may  come  into 
play)  heredosyphilis  appears  to  be  the  only  cause. 

The  severe  protracted  general  infection  of  the 
foetus  or  newborn  child  must  have  a  marked  influence 
upon  the  young  enamel  cells  during  the  time  they  are 
forming  the  enamel.  The  slightest  injury  at  this 
time  even  of  very  short  duration  causes  an  irreparable 
defect  in  the  enamel.  However,  during  periods  of 
remission  of  the  damaging  process  the  development 
of  the  enamel  continues.  Thus  ridges  and  depressions 
are  formed  upon  the  tooth  corresponding  respectively 
to  periods  of  remissions  and  exacerbations  of  the  dis- 
ease. The  disturbance  shows  itself  either  in  the 
enamel  not  forming  at  all  or  in  the  forming  an  uneven 
huiii])ed-np  layer  of  enamel  differing  in  thickness  and 
of  diminished  resistance,  in  place  of  the  smooth  sym- 
metrical layer.  At  the  aflPected  part,  the  tooth  be- 
comes rough  and  brittle  and  in  particular  situations 
the  enamel  is  wanting  and  the  dentin  lies  exposed. 
The  lesion  has  the  appearance  of  an  erosion.  The 
changes  are  not  from  a  loss  of  substance  but  from 
a  defective  growth  and  development.  At  first,  little 
by  little,  the  places  of  diminished  resistance  through 
eliewing  Ijccome  worn  away  and  then  there  ai)pears 
a  true  erosion.  This  wearing  away  does  not  take 
place  if  the  defect  is  on  the  crown  nearer  the  gingival 
border  of  the  tooth  where  most  of  the  parallel  ridges 
and  dcjjrcssions  can  persist  during  life. 

The  most  frequently  seen,  best  known,  and  the 

40 


first  described  of  these  imperfectly  developed  teeth 
where  the  so-called  Hutchinson  teeth  (Figs.  27,  52, 
53,  54  and  56)  in  which  the  defect  is  seen  at  the 
morsal  margin  of  the  two  upper  central  incisors  ("the 
test  teeth").  Usually  the  teeth  are  narrower  at  the 
gingival  and  morsal  margins  of  the  crown  and  are 
thus  oval  in  shape,  or  they  gradually  narrow  from  the 
gingival  to  morsal  margin  and  are  peg-shaped.  The 
middle  of  the  facial  surface  of  the  crown  is  often 
arched  forward  and  the  lower  end  of  the  tooth  grad- 
ually runs  to  a  sharp  point.  This  deformity  is  best 
seen  from  the  side. 

The  length  and  the  intensity  of  the  injury  de- 
termines the  defect.  It  can  be  indicated  by  only  a 
small  rough  spot  on  the  morsal  margin  of  the  tooth  or 
by  a  small  notch  which  may  also  extend  to  the  middle 
of  the  tooth.  In  marked  cases  it  is  seen  as  a  crescentic 
shaped  cut-out  portion  of  the  morsal  margin  which 
by  the  wearing  away  of  the  tooth  becomes  gradually 
deeper.  The  surface  of  the  cut-out  portion  is  uneven 
(humped  up)  and  of  a  brovraish-yellow  color  differ- 
ing markedly  from  the  normal  enamel  of  the  rest 
of  the  tooth.  The  pointed  corners  of  the  incisors  be- 
ing gradually  worn  away  disappear,  leaving  only 
short  incisor  teeth;  so  that  typical  Hutchinson  teeth 
have  usually  disappeared  in  middle  aged  syphilitic 
subjects. 

If  the  damaging  process  to  the  two  upper  central 
incisors  extends  over  a  long  period,  then,  as  a  rule, 
the  upper  lateral  incisors  and  all  the  lower  incisors 
are  aflFected  and  the  morsal  edges  of  the  canines  also 
show  a  rough  surface.  In  such  a  case  not  only  is 
there  an  hypoplasia  of  the  morsal  edge  of  the  incisors 
as  indicated  by  the  crescent-shaped  notches,  but  the 
hypoplasia  may  even  involve  one-quarter  to  one-tliird 
(Figs.  58  and  62)  of  that  part  of  the  tooth  nearer  the 
gingival  margin.  The  original  Hutchinson  teeth  are 
caused  by  syphilis  in  the  first  weeks  or  months  after 
birth,  i.e.,  at  the  period  when  the  heredosj'philis  is 

41 


at  its  worst  in  extrauterine  life,  and  when  it  most 
often  runs  a  lethal  course. 

That  more  frequent  but  less  known  form  of  hypo- 
plasia of  the  morsal  surface  of  the  first  molar  dates 
from  the  last  months  of  intrauterine  life  (Figs.  53, 
56,  57,  60.  61  and  62).  The  morsal  end  of  the  cro-vvn 
is  atrophied,  the  morsal  surface  has  an  irregular 
rough  surface  with  spicules  and  craterlike  eleva- 
tions and  in  place  of  the  smooth  white  surface,  an 
amorphous  dirty  grayish-yellow  mass  is  seen. 
The  extent  of  the  degeneration  is  determined 
by  the  duration  and  time  of  the  inception  of 
the  disturbance.  It  may  be  confined  to  the  ex- 
treme ends  of  the  cusps  so  that  they  appear  as 
if  thev  were  worn  away  by  sand,  or  it  can  attack 
one-quarter  to  one-third  of  the  cro'svii.  This  part  of 
the  crown  with  its  diminished  diameters  rests  upon 
the  normal  stumplike  part  of  the  tooth  (Figs.  60 
and  61 )  as  a  kind  of  atrophied  and  irregularly  shaped 
tooth.  These  defective  morsal  surfaces  have  only  a 
limited  existence.  They  wear  away  and  a  yellow  or 
bro\mish-yellow  depression  takes  the  place  of  the 
protuberance,  which  is  surrounded  by  a  white  border 
of  dentin.  It  is  quite  striking  how  this  anomaly  al- 
ways involves  the  four  first  molars  in  the  same  way 
and  at  the  same  time. 

These  eroded  areas  naturally  form  a  favorable 
groTind  for  caries  of  the  tooth,  and  thus  it  is  that  these 
four  teeth  either  at  once  undergo  caries  or  go  en- 
tirely to  pieces,  while  the  rest  of  the  teeth  are  in  good 
condition;  or  on  one  or  more  of  the  first  molars  there 
is  degeneration  of  the  morsal  surfaces  and  on  the 
remaining  caries  (always  a  central  caries  involving 
that  part  of  the  tooth  immediately  underlying  the 
eroded  portion).  The  first  molar  teeth  have  an  es- 
pecial predilection  for  caries;  their  early  calcification 
appears  less  resistant  to  caries  than  the  rest  of  the 
permanent  teeth.  The  symmetrical  central  caries  of 
the  four  first  molars  is  a  very  suspicious  sign,  and  the 

42 


hypoplasia  of  the  inorsal  surfaces  of  these  teeth  is 
distinctly  pathognomonic. 

Of  48  cases  where  these  lesions  were  seen,  16  were 
without  doubt  heredosyphilitics;  18  were  very  suspi- 
cious, as  the  patients  had  either  Hutchinson's  teeth, 
or  syphilitic  parents  or  heredosyphilitic  brothers  or 
sisters.  In  6  cases  syphilis  could  not  be  excluded  en- 
tirely and  only  in  8  cases  was  there  no  absolute  proof 
of  heredosyphilis. 

An  hypoplasia  similar  to  that  on  the  first  molars 
is  occasionally  seen  on  other  teeth,  viz.:  on  the  lower 
incisors  where  sometimes  the  atrophied  pointed  end 
resembling  a  clove  is  implanted  upon  the  base  of  the 
crown  (Fig.  59). 

In  how  far  the  numerous  other  irregularities  in 
shape  and  position  of  the  teeth  (sharklike  teeth,  ab- 
normally formed,  twisted  teeth,  obliquely  placed 
teeth,  asymmetrical  teeth,  microdentism,  the  absence 
of  a  single  tooth  or  groups  of  teeth,  the  persistence 
of  the  deciduous  teeth)  can  be  connected  with  syphilis 
is  doubtful.  Yet,  it  is  striking  how  these  deformities 
appear  synchronously  with  the  other  signs  of  heredo- 
syphilis and  especially  with  true  syphilitic  teeth. 

As  already  mentioned  the  hypoplasic  defects  of 
the  teeth  arising  at  a  later  period  in  the  course  of 
heredosyphilis  appear  in  a  form  which  cannot  be  dis- 
tinguished, without  further  studying  the  cause,  from 
that  produced  by  rickets.  Teeth  with  pits,  depres- 
sions, holes,  parallel  furrows  crossing  the  crown  and 
irregularly  formed  crowns  may  be  caused  by  rachitis. 
But  rickets  is  not  to  be  regarded  as  the  only  cause, 
especially  if  accompanying  changes  appear,  such  as 
hypoplasia  of  the  morsal  surface  of  the  first  molars 
which  must  have  begun  shortly  before  birth. 

What  has  been  said  of  changes  in  the  teeth  occa- 
sioned by  heredosyphilis  refers  to  the  permanent 
teeth.  Very  rarely  are  such  disturbances  seen  in  the 
■deciduous  teeth.    Disturbances  of  calcification  of  the 

43 


deciduous  teeth  in  heredosyphilis  are  not  often  ob- 
sen^ed. 

Hypoplasia  of  the  deciduous  teeth  is  not  to  be 
distinguished  from  that  of  the  permanent  teeth,  the 
crescentic  notches  being  seen  most  often  upon  the  in- 
cisor teeth. 


44 


Diseases  Similar  to  the  Lesions  of  Secondary  Syph- 
ilis of  the  Mouth 

Traumatic  changes  in  the  mucous  membrane  of 
the  mouth  resembling  syphihs  can  be  produced  in 
many  ways,  viz.:  by  mechanical  injury,  or  corrosive 
substances  and  burning,  and  appear  as  if  the  mucous 
membrane  had  been  painted  with  a  weak  solution  of 
silver  nitrate  and  thus  give  somewhat  the  picture  of 
mucous  patches  of  the  mouth.  Among  all  the  forms 
of  mechanical  injury  to  which  the  mouth  is  subjected 
biting  is  the  most  frequent,  and  ulcers  may  be  caused 
by  the  sharp  borders  of  carious  or  fractured  teeth. 
There  is  sometimes  found  on  the  nmcous  membrane 
of  the  cheeks  quite  a  dense  chronic  infiltration  with  a 
grayish-white  cicatricial  surface,  which  may  ulcerate. 
F'aulty  articulation  by  oft-repeated  biting  of  this 
surface  causes  and  maintains  this  condition.  Such 
a  lesion  is  especially  difficult  to  diagnose  from  a 
mucous  patch,  since  the  syphilitic  process  has  a  predi- 
lection for  this  locality.  In  such  cases  repeated  ob- 
servations and  all  adjunct  diag/iostic  means  are  nec- 
essary for  a  diagnosis. 

Injuries  to  the  Frenum  Linguce  are  frequently 
seen  in  children  soon  after  the  eruption  of  the  lower 
incisor  teeth  and  especially  in  those  who  are  suffering 
from  whooping-cough.  In  this  disease  the  tongue  is 
more  or  less  protruded  on  account  of  the  coughing 
and  choking,  and  the  ulcers  found  on  its  under  sur- 
face are  continually  irritated  and  kept  open  by  the 
sharp  teeth.  These  sublingual  ulcers,  on  account  of 
their  persisting,  refractory  character,  may  be  mis- 
taken for  syphilis. 

45 


The  apparent  cause  of  these  ulcers  and  the  ab- 
sence of  any  other  suspicious  sypliihtic  lesion  on  the 
body  excludes  a  diagnosis  of  syphilis,  even  if  the  diag- 
nosis of  syphilis  is  made  by  the  father  himself  who 
was  formerly  syphilitic. 

Tlie  Ulcers'  of  the  Palate— the  So-Called  "Bed- 
nar's  Aphthcv" — of  the  nursing  child  are  probably 
caused  by  the  sucking  of  rubber  nipples  or  the  ex- 
cessive cleaning  of  the  mouth.  These  ulcers  might  be 
syphilitic.  But  their  characteristic  localization  upon 
the  raphe  of  the  hard  palate  and  the  absence  of  other 
signs  of  syphilis  makes  such  a  diagnosis  improbable. 

Although  the  clinical  manifestations  of  Stomatitis 
Mercurialis  (Mercurial  Stomatitis)  are  generally 
very  characteristic,  yet  it  is  occasionally  very  difficult 
to  diagnose  it  from  syphilis.  The  reason  for  this  is 
that  papules  and  ulcerations  caused  by  the  mercury 
may  appear  in  the  mouth,  and  mercurial  intoxication 
occurs  almost  exclusively  in  those  who  have  taken 
mercurial  treatment,  i.e.,  in  syphilitic  subjects.  If 
the  syphilitic  attempts  to  treat  himself,  and  there  are 
apparent  indications  justifying  the  treatment,  the 
mercurial  idcerations  may  be  mistaken  for  stubborn 
syphilides  which  are  kept  up  by  the  continued  mer- 
curial treatment. 

Tlie  typical  mercurial  stomatitis  (Figs.  30  and 
31 )  witli  its  diffuse  redness  and  swelling  of  the  mu- 
cous membrane,  the  profuse  salivation,  the  idcerations 
covered  with  pus  u])on  tlie  gums,  the  swelling  of  the 
tongue,  the  deep  often  sloughing  ulcers  made  by  in- 
dentations of  the  teeth  upon  the  edges  of  the  tongue 
and  the  mucous  meml)rane  of  the  cheeks,  together 
witli  the  al)()iiiinable  ffX'tor,  is  not  easilj^  mistaken  or 
forgotten.  IJut  if  the  lesions  occur  only  in  one  or  more 
spots  determined  by  trauma,  it  is  not  easy  to  de- 
cide whether  wc  are  dealing  willi  syj)hilitic  ulcera- 
tions or  a  local i'/ed  mercurial  stomatitis.  Such  spots 
arc  most  often  seen  eitlier  in  the  angle  of  the  man- 
dible, where  the  mucous  membrane  of  the  cheek  oppo- 

46 


site  the  last  molars  is  pinched  and  bruised,  or  on  the 
gum  over  a  partially  erupted  wisdom  tooth.  Both  the 
mercurial  and  syphilitic  ulcerations  have  a  predilec- 
tion for  these  localities  and  if  there  are  no  especially 
distinguishing  features  to  support  the  diagnosis,  it 
cannot  be  made.  Mercurial  poisoning  may  lead  to 
extensive  ulcerations  in  the  region  of  the  tonsils  and 
lower  part  of  the  soft  palate.  The  ulcerations  are 
covered  with  a  white  necrotic  membrane  and  cannot 
be  distinguished  from  diphtheria,  especially  if  there 
is  only  a  single  spot  and  the  other  manifestations  of 
mercurial  poisoning  are  absent  or  very  slight  (Fig. 
32). 

The  other  toxic  causes  of  lesions  in  the  mouth 
which  may  resemble  syphilis  are  all  such  drugs  which 
can  occasion  upon  the  skin  the  so-called  Medicamen- 
tous  Eruptions.  JNIedicamentous  eruptions  of  the 
mucous  membrane  of  the  mouth  are  much  less  fre- 
quent and  more  insignificant  than  those  of  the  skin. 

Potassium  iodide  and  other  alkaline  iodides  al- 
most always  cause  the  formation  of  more  or  less  pro- 
nounced pustules  in  the  skin.  A  light,  diffuse 
catarrhal  reddening  is  seen  accompanying  the  iodic 
coryza. 

With  the  administration  of  halsamics  no  oral 
manifestations  are  observed. 

The  use  of  phenacetin,  antipyrin  and  antipyrin- 
containing  drugs,  e.g.,  pyramidon,  migranin,  sali- 
pyrin,  etc.  (Fig.  33)  causes  an  eruption  of  the  oral 
mucous  membrane  which  may  be  not  unlike  that  of 
syphilis.  It  is  not  unlike  that  of  erysipelas.  It  is  not 
difficult  to  diagnose  the  erythema  occasioned  by  any 
of  these  drugs.  Sometimes  protracted  circumscribed 
infiltrates  arise  and  the  upper  layers  of  the  epithe- 
lium, especially  of  the  tongiie  and  cheeks,  desquamate 
in  spots,  thus  occasioning  an  error  in  diagnosis.  The 
medicamentous  exanthem  often  occurs  upon  the  geni- 
talia so  that  the  genital  affection  appears  to  confirm 
the  diagnosis  of  syphilis  of  the  mouth.    However,  the 

47 


sudden  appearance  of  the  mouth  lesion,  as  a  rule, 
sjTichronous  with  the  eruption  upon  the  other  parts 
of  the  body,  together  with  the  history  of  the  case  per- 
mits of  an  exclusion  of  the  diagnosis  of  syphilis. 

The  participation  of  the  mucous  membrane  of  the 
mouth  hi  acute  infectious  diseases.  Scarlatina,  Mea- 
sles, Varicella,  etc.,  will  at  least  give  some  slight  occa- 
sion for  confusing  lesions  of  these  diseases  which  may 
appear  in  this  locality  with  those  of  syphilis. 

A  single  efflorescence  of  the  mucous  membrane, 
e.g.,  in  varicella,  and  the  scarlatina  angina  may  occa- 
sionally resemble  a  syphilitic  erosion  or  mucous  patch. 
The  entire  picture  and  course  of  these  diseases  do  not 
permit  of  confusion.  There  are  some  lesions  of  the 
mucous  membrane  of  the  mouth  which  occur  as  part 
manifestations  of  Chronic  or  Acute  Skin  Diseases 
and  may  be  very  difficult  to  diagnose  as  they  may 
be  confined  entirely  to  the  mouth. 

Eczema  and  Psoriasis  do  not  involve  the  mucous 
membranes. 

Lichen  Ruber  Planus  (Fig.  34)  occurs  com- 
paratively often  in  the  mucous  membrane  of  the 
mouth,  and  its  efflorescence  is  like  that  of  the  skin. 
There  are  many  miliary  flattened,  often  umbilicated, 
grayish  papules  of  a  horny  character,  which  do  not  un- 
dergo pustular  transformation,  with  no  inflammatory 
border.  In  protracted  cases  the  papules  may  coalesce 
forniing  patches  which  may  be  of  a  ring  or  arched 
shape;  they  may  even  resemble  a  mosaic.  Their  seat 
of  predilection  is  the  mucous  membrane  at  the  middle 
of  the  cheek,  the  lips  and  tongue.  So  long  as  it  is 
evident  that  the  patches  are  made  up  of  papules  or 
that  a  single  typical  isolated  i)ai)ule  can  be  seen  at  the 
periphery  of  the  patch  the  diagnosis  is  not  difficult. 
The  appearance  of  lichen  ruber  on  the  skin  at  the 
time  of  its  occurrence  in  the  mouth  will  also  indicate 
the  nature  of  the  disease.  If  the  lichen  ruber  appears 
on  the  mucous  membrane  of  the  mouth  alone  in  the 
form  of  large  gray  patches,  as  they  may  be  seen  upon 

48 


the  tongue;  or  possibly  as  an  atypical  single  manifes- 
tation upon  the  glans  penis;  it  is  extremely  difficult 
for  even  an  experienced  observer  to  make  a  differen- 
tial diagnosis.  The  diagno.sis  is  further  complicated 
by  the  slow  development  of  the  disease,  its  chronic 
course  and  the  absence  of  any  considerable  subjective 
symptom.  This  disease,  which  undergoes  less  and 
slower  changes  than  syphilis,  should  be  carefully 
studied.  It  never  attacks  the  mucous  membrane  of 
the  soft  palate  or  tonsils  and  does  not  react  to  either 
local  or  general  antisyphilitic  treatment.  The  result 
of  the  Wassermann  reaction  is  not  decisive.  The 
presence  of  the  treponema  pallidum  in  the  lesions  is 
conclusive. 

Pemphigus  occasionally  attacks  the  mouth.  The 
entire  mucous  membrane  becomes  covered  with  bullie. 
Some  of  the  bulla  may  rupture,  forming  easily  bleed- 
ing excoriations  bordered  by  epithelial  debris  and 
covered  with  a  fibrinous  membrane.  Some  bullae 
may  subside  without  rupturing.  The  suddenly  oc- 
curring and  quickly  healing  excoriations  scarcely  ever 
appear  confined  to  the  mouth  but  form,  as  a  rule,  a 
part  of  the  manifestation  of  a  severe  general  pem- 
phigus and  therefore  the  disease  is  not  likely  to  be 
confused  with  syphilis.  The  involvement  of  the  mu- 
cous membrane  of  the  mouth  in  pemphigus  is  an  un- 
favorable prognostic  symptom. 

In  Dermatitis  Herj)etiformis  the  mucous  mem- 
brane of  the  mouth  is  often  attacked  in  a  similar 
manner. 

The  mucous  membrane  of  the  mouth  may  be  af- 
fected by  Erythema  Multiforme  Exsudativum  (Fig. 
35).  (Idiopathic  Polymorphous  Erythema.)  This 
first  appears  as  an  erythema,  which  is  followed  by 
the  formation  of  buUfe.  These  bulla  develop  more 
slowly,  are  not  so  superficial,  and  do  not  rupture  so 
easily  as  those  of  pemphigus,  and  often  contain  blood, 
which  can  coagidate.  Sometimes  they  lead  to  lesions 
covered  with  layers  of  adherent  yellowish  fibrin  which 

49 


on  removal  cause  bleeding  of  the  ei'oded  membrane. 
The  clinical  ajjpearance  of  erythema  multiforme  ex- 
sudati^aml  distinguishes  itself  in  many  details  from 
the  syphilitic  affections  of  the  mouth.  When  the 
disease  is  fully  developed  the  lesions  are  character- 
istic; while  in  the  beginning  and  decline  it  lacks 
individuality  and  can  be  easily  mistaken.  The  pres- 
ence of  similar  spots,  at  the  same  time,  on  other  parts 
of  the  body  facilitates  diagnosis.  Still  the  erythema 
exsudativum  also  occurs  isolated  ujDon  different 
places  of  the  mucous  membrane  of  the  mouth. 

Purpura  HcemorrJiagica  of  the  mouth  might  pos- 
sibly resemble  syphilis.  The  hemorrhages  into  the 
mucous  membrane,  however,  are  easy  to  recognize  as 
such.  They  appear  by  predilection  on  the  gums, 
■when  on  the  hard  or  soft  palate  thej'  develop  into 
bluish-red,  mostly  serrated,  sharply  marked  off  spots. 
Their  sudden  non-protruding  appearance  in  the 
mucous  membrane  and  gradual  resorption  with  the 
well-known  changes  in  color  characterize  them  as 
hemorrhages  into  the  mucous  membrane. 

Herpes  Facialis  (Fig.  36)  is  usually  found  on  the 
lips.  From  here  it  extends  to  the  mouth  or  it  may 
attack  the  mouth  alone.  The  flat  idcers  resemble 
mucous  })atches  of  tlie  mouth.  Their  formation  from 
groups  of  vesicles  and  the  polycyclic  form  of  the 
eruption  precludes  any  doubt  as  to  their  being  syphi- 
litic. 

In  buccal  Herpes  Zoster  the  eruption  is  located  in 
a  definite  nerve  region  and  is  accompanied  by  neural- 
gic pain  and  swelling  of  the  adjoining  lymph  nodes. 

The  Aphthous  Ulcers  of  the  mouth  in  Stomatitis 
yiphthosa  (Stomatitis  Macnlo-Fihrinosa,  ^Iphtlious 
Stomatitis)  (Fig.  37)  may  be  confused  with  syphilis 
:ui(l  may  also  be  a  cause  for  alarm  in  patients  who  are 
suffering  from  latent  syphilis.  In  most  cases  it  is 
not  difllcnlt  to  make  a  differential  diagnosis.  The 
aphllious  nicer  appears  suddenly,  either  singly  or  in 
groups,  as  a  superficial  flat,  hollowed  out  erosion. 

50 


The  surroiiiuiiiig  iiiucous  membrane  is  red,  inflamed 
and  a  little  raised.  The  edge  of  tlie  erosion  is  sharp, 
sometimes  it  is  marked  off  by  a  very  narrow  l)right 
red  border.  The  pateh  is  covered  with  a  bright  yel- 
low fibrinous  membrane,  which  after  1  or  '1  days  as 
it  loosens  and  detaches  itself  from  the  ulcer  becomes 
grayish.  The  process  rims  its  course  in  4  or  5  days. 
The  aphthous  spots  appear  either  alone  or  in  groups, 
at  the  same  time  or  in  sequence,  so  that  different 
stages  can  occasionally  be  observed  in  their  develop- 
ment. They  are  usually  situated  on  the  mucous  mem- 
brane of  the  lips,  cheeks,  gums  and  frenum  linguas. 
The  single  patches  have  a  definite  size  when  they  ap- 
pear, which  is  maintained  until  they  disappear.  They 
have  but  little  tendency  to  peripheral  growth,  but 
neighboring  spots  may  undergo  confluence  in  the 
form  of  a  figure  8.  Pain,  which  is  a  very  character- 
istic symptom  of  this  disease,  especially  if  the  lesions 
are  extensive,  makes  the  eating  of  solid  food  impos- 
sible. This  is  a  most  important  symptom  in  dis- 
tinguishing these  aphthous  patches  from  syphilitic 
mucous  patches.  Tlie  latter,  however,  do  not  appear 
so  suddenly ;  are  grayish-white ;  not  so  highly  colored, 
have  less  signs  of  inflammation,  run  a  chronic  course; 
and  have  a  tendency  to  peripheral  growth.  There 
are  cases  where  the  differential  diagnosis  of  an  aph- 
thous iflcer  from  a  mucous  patch  solely  by  the  clinical 
signs  is  simply  impossible,  and  there  are  also  cases 
where  aphtlious  iflcers  appear  in  subjects  with  latent 
syphilis.  In  any  of  such  cases  the  finding  of  the  tre- 
ponema  pallidum  in  the  lesion  determines  the  diag- 
nosis. 

The  lesions  of  TJintsh  {Parasitic-Mycotic  Stoma- 
titis), which  usually  appear  in  nursing  children,  are 
not  easily  confused  with  syphilis.  The  irregular  white 
membranes  in  the  form  of  dots,  stripes,  or  several  of 
these  connected  together  and  growing  and  extending 
rapidly  over  a  congested  mucous  membrane  cannot  be 
mistaken.    The  presence  of  the  oidum  albicans  in  the 

51 


lesions,  which  is  not  difficult  to  find,  confirms  the 
diagnosis.  It  is  comparatively  seldom  that  a  form 
of  Angina  FoUicularis  (Fig.  38)  (Follicular  Tonsil- 
litis) suggests  syphilis,  as  the  fever,  acute  inflamma- 
tion, congestion,  swelling  and  the  localization  of 
"plugs"  in  the  openings  of  the  follicles  are  distin- 
guishing features.  It  has  been  stated  that  there  are 
cases  in  wliich  the  syphilitic  mucous  patches  can  local- 
ize about  the  follicular  openings,  the  syphilitic  angina 
taking  a  course  similar  to  that  of  the  follicular  angina. 
The  follicular  stage  of  the  syphilitic  angina  passes 
quickly,  the  mucous  patches  run  together,  appear  in 
other  places  or  extend  and  involve  even  the  arch  of 
the  palate.  The  two  pictures  are  very  different.  But, 
it  must  not  be  forgotten  that  occasionally  both  forms 
of  angina  ai)pear  at  the  same  time  (Fig.  39). 

Under  some  conditions  it  is  difficult  to  make  a 
differential  diagnosis  between  a  sj'philitic  angina  and 
a  mild  case  of  diphtheria  (Fig.  40).  The  differences 
are  marked  in  pronounced  cases.  In  diphtheria  there 
is  the  acute  onset,  fever,  active  inflanmiatory  reac- 
tion, the  white  rapidlj'  extending  false  membrane,  the 
great  pain  and  difficulty  in  swallowing,  etc.  In  the 
syphilitic  angina  the  course  is  chronic,  there  is  slight 
inflammatory  reaction  and  the  gray  false  membrane 
either  does  not  extend  or  does  so  but  slowly.  But 
there  are  cases  where  a  severe  papular  syphilitic  an- 
gina resembles  a  moderate  diphtheria.  A  mild  syphi- 
litic angina  can  appear  diphtheroid  if  the  false  mem- 
brane is  particularly  white,  and  if  fever  and  severe 
general  symptoms  are  present.  Sometimes  a  true 
case  of  diphtheria  (Krurs  without  especially  high  fever 
or  noticeable  subjective  disturbances.  In  all  such 
cases  a  false  diagnosis  may  be  made  if  we  rely  on  the 
clinical  picture  alone.  [The  ])resence  of  the  Klcbs- 
LofJIcr  bacillus  in  the  lesion  determines  the  diagnosis 
in  these  obscure  cases. — Th.]  It  has  been  stated 
above,  that  a  mercurial  stomatitis  can  occasionally  re- 
semble a  diphtheritic  or  syphilitic  anguia. 

52 


SfoTnatitis  Ulcerosa  or  Stomacace  (Ulcerative 
Stomatitis),  appears  mostly  in  enfeebled  individuals, 
espeeially  children  who  have  been  debilitated  by  some 
such  disease  as  measles  or  typhoid  fever,  etc.  Some- 
times it  is  epidemic.  The  clinical  picture  closely  re- 
sembles that  of  mercurial  stomatitis. 

Generally  the  process  in  ulcerative  stomatitis  is 
less  diffuse  than  in  mercurial  stomatitis.  The  gums 
are  less  and  the  mucous  membrane  of  the  cheeks  more 
often  involved.  Severe  pain  accompanies  a  marked 
swelling  and  redness  of  the  mucous  membrane.  The 
latter  quickly  changing  to  a  bluish  color.  Flat  bullas 
are  formed  which  rupture  after  a  short  time  forming 
ulcers  with  a  dirty  grayish  yellowish  necrotic  mem- 
brane, which  goes  to  pieces  and  produces  a  most  of- 
fensive odor.  The  ulcers  may  form  without  passing 
through  the  bullous  stage.  The  ulcers  extend  not 
only  superficially  but  deeply.  The  lymph  ganglia 
are  swollen,  painfully  inflamed  and  may  suppurate. 
Fever  is  present  and  the  patients  are  quickly  debili- 
tated not  because  they  are  imable  to  take  food  on 
account  of  the  pain  it  occasions,  but  on  account  of 
a  septic  pneumonia  or  general  sepsis  which  may  take 
a  lethal  course. 

From  the  ulcerated  stomatitis  on  the  mucous  mem- 
brane of  the  cheek  there  can  develop  a  fulminating 
gangrene  of  the  cheek,  the  so-called  Noma  {Cancrum 
Oris,  Gangrenous  Stomatitis) .  It  is  not  known 
whether  ulcerated  stomatitis  has  a  determined  etiol- 
og>'.  The  bacteriological  side  of  this  question  is  not 
clear.  The  numerous  spirochstas  found  in  ulcerated 
stomatitis  have  not  been  differentiated  from  those 
frequently  found  in  the  healthy  mouth,  e.g.,  the  spi- 
rochreta  buccalis,  etc. 

Plant  and  Vincent  described  an  angina  appearing 
sometimes  in  a  diphtheroid  and  oftentimes  in  an  ul- 
cerated form.  Large  spirocha?ta;  and  fusiform  bacilli 
were  constantly  found  in  these  lesions  (Fig.  72). 
The  synchronous  appearance  of  lesion  and  microor- 

53 


ganisms  is  regarded  as  characteristic  of  the  Plaut- 
Vinccnt  Angina.  While  the  severe  ulcerative  stoma- 
titis can  scarcely  be  confused  with  any  form  of  syphi- 
lis, the  mild  and  sometimes  very  chronic  course  of  the 
Plant-Vincent  angina  can  resemble  an  ulcerated 
syphilitic  process  and  make  the  differential  diagnosis 
extremely  ditHcult. 

The  finding  of  the  treponema  pallidum  in  the 
lesion  will  render  the  decision  for  syphilis.  On  the 
other  hand,  the  presence  of  coarse  thick  spirochtetae 
associated  witli  fusiform  bacilli  has  no  great  diagnos- 
tic worth  in  favor  of  the  Plaut-Vinccnt  angina,  as 
such  a  finding  can  occur  in  ulcerated  syphilis  of  the 
mouth. 

The  Plant-Vincent  disease  and  allied  conditions, 
such  as  an  ulcerative  angina  may  resemble  a  chancre 
of  the  tonsil.  The  fact  that  it  runs  a  slow  course, 
gives  relatively  little  trouble,  and  causes  an  involve- 
ment of  the  sub-maxillary  lymph  nodes  may  make  the 
diagnosis  difficult   (Fig.  41). 

There  may  appear  in  the  mouth  persistent  ulcer- 
ative processes  resulting  from  Trauma  which  not 
only  in  their  clinical  picture  but  also  in  their  course 
very  closely  reseml)le  syphilitic  ulcerations.  They 
must  be  studied  closely  for  some  time  before  a  diag- 
nosis can  be  made  (Fig.  42). 

It  is  easy  to  distinguish  from  syphilis  the  severe 
inflaiiHiiatory  diseases  of  the  mouth  such  as  the  Foot 
and  Mouih  Disease  in  man  and  Those  Stomatites 
the  Causal  Agent  of  Which  is  Unknown,  because, 
like  the  ulcerative  stomatitis,  they  are  very  active  and 
take  a  rapid  course. 

The  colonization  of  Fungi  and  the  Leptothrix 
Buccalis  can  produce  an  extremely  stubborn  form  of 
angina,  which  on  account  of  its  chronicity  and  slight 
inflammatory  reaction  may  very  well  be  taken  for 
syphilis.  The  masses  of  fungi  arc  situated  like  plugs 
in  the  openings  of  the  follicles  of  the  tonsils. 

.iVfler  the  plugs  have  i)ersisted  for  some  time 

54 


they  become  hard  owing  to  the  presence  of  substances 
other  than  the  fungi,  viz.:  epithelial  debris  and  cal- 
careous matter  and  may  project  more  than  a  milli- 
metre from  the  orifices  of  the  follicles  (Fig.  43). 
The  microscope  will  easily  prove  the  presence  of  the 
fungus. 

Lingua  Geographica  {The  Geographical 
Tongue)  (Fig.  44).  The  nature  and  cause  of  this 
very  peculiar  condition  of  the  mucous  membrane  of 
the  tongue  is  not  clear.  The  tongue  itself  may  not 
be  changed  at  all.  In  most  cases  it  is  however  a  little 
thicker  and  shows  the  imprint  of  the  teeth  on  its 
edges.  ]Many  folds  and  furrows,  the  latter  more  or 
less  deep,  traverse  the  surface  of  the  tongue  which 
gives  it  a  flattened  form  or  at  the  edges  a  pulled  out 
and  fringed  appearance  {Lingua  plicata). 

The  most  important  and  characteristic  symptom 
is  a  peculiar  thickening  of  the  epithelium.  These 
thickened  epithelial  spots  as  they  spread  assume  ring 
and  bow-shaped  forms  which  have  a  more  or  less 
bright  red,  sometimes  remarkably  smooth  centre 
(Fig.  45).  The  bow-shaped  forms  are  raised  a  little 
above  the  normal  mucous  membrane,  have  a  gray  or 
yellowish-gray  color  and  are  often  covered  with 
epithelial  debris,  which  loosely  adheres  to  the  mucous 
membrane.  The  uninvolved  part  of  the  mucous  mem- 
brane of  the  tongue  can  have  a  perfectly  normal  ap- 
pearance, although  it  is  usually  slightly  coated  and 
the  filiform  papilljE  are  especially  well  developed. 

Rapid  change  is  particularly  characteristic  of  this 
condition.  The  configuration  of  the  tongue  can 
change  from  day  to  day.  Sometimes  the  rings  grow, 
sometimes  they  disappear  entirely,  leaving  an  appar- 
ently normal  mucous  membrane.  But  the  aspect  of 
the  tongue  is  never  normal,  on  some  part  of  its  mu- 
cous membrane  new  jjoints  and  rings  are  reappear- 
ing. It  is  not  known  what  these  changes  are  or  what 
causes  them. 

Not  even  a  rapidly  developing  herpes  tonsurans 

55 


or  an  annular  syphilide — at  best  only  pemphigoid 
and  erythematous  lesions — can  pass  through  such  and 
so  many  changes  in  a  few  days  as  are  to  be  seen  upon 
the  geographical  tongue.  Therefore  the  geographical 
tongue  is  sometimes  designated  "Annidus  migrans" 
or  "Wandering  Bash."  The  condition  exists  at 
birth  and  lasts  during  life.  Sometimes  it  shows  itself 
but  slightly,  at  otliers  it  appears  in  its  severest  form. 
It  usually  gives  no  trouble  and  there  are  many  who 
have  no  presentiment  of  the  condition  of  their  tongue. 
Some  are  sensitive  to  mechanical  stimulation  (can- 
not eat  hard  bread,  nuts,  etc.)  and  are  inclined  to 
develop  glossitis,  which  however  is  transitory.  The 
cause  of  the  condition  is  unknowii.  It  has  been  at- 
tributed to  an  exudative  diathesis  and  has  been 
looked  upon  as  a  manifestation  of  scrofula.  Against 
these  surmises  we  have  the  facts  that,  it  has  been  seen 
immediately  after  birth  and  that  it  remains  through- 
out life  in  spite  of  all  kinds  of  therapy. 

The  geographical  tongue  is  surel_y  not  syphilitic, 
but  it  resembles  very  much  those  changes  which  are 
caused  by  an  annular  syphilide  of  the  mucous  mem- 
brane and  on  superficial  inspection  may  be  easily  mis- 
taken for  an  annular  syphilide.  If  there  are  discrete 
spots  (about  5  mm.  in  diameter)  or  small  bow-formed 
areas  where  the  epithelium  is  thickened,  the  diagnosis 
becomes  difficult  and  can  only  be  made  by  repeated 
examinations  and  availing  one's  self  of  all  accessory 
means  [Wasscrmann  reaction,  dark-field-microscope, 
etc, — Tr.]  of  diagnosis.  Syphilis  and  a  geographi- 
cal tongue  can  be  present  at  the  same  time  and  with 
such  an  occurrence  the  difficulty  of  a  differential  di- 
agnosis is  obvious. 

Although  there  is  no  doubt  but  that  TjCiikopIalda 
Buccalis  is  not  exclusively  a  syphilitic  lesion,  never- 
theless there  is  also  no  doubt  that  syphilis  in  a  great 
measure  predetermines  conditions  for  its  occurrence, 
ami  fliat  an  especially  high  percentage  of  those  who 
suffer  from  leukoplakia  arc  syphilitic. 

5G 


The  predisposing^  factors  are:  chronic  irritation  of 
the  nuieous  membrane  of  the  mouth,  especially  smok- 
ing and  chewing,  excessive  use  of  strong  alcoholic 
drinks  and  highly  seasoned  foods,  etc. 

Leukoi)lakia  huccalis  (Fig.  46)  is  a  chronic  thick- 
ening and  cornification  of  the  epithelium  of  the  mu- 
cous membrane.  So  that  the  mucous  membrane  is 
covered  with  a  callous  or  rindlike  membrane.  Both 
leukoplakia  buccalis  and  lingualis  are  sometimes 
called  psoriasis  buccalis  and  lingualis,  which  is  incor- 
rect, as  psoriasis  never  attacks  the  mouth.  Leuko- 
plakia buccalis  usually  appears  as  several  discrete 
light  bluish-gray  spots,  which  in  time  coalesce,  form- 
ing larger  spots,  and  in  extreme  cases  the  entire 
tongue  is  involved.  The  gums  usually  escape  or  are 
attacked  last  of  all.  The  first  si)ots  which  are  very 
thin  and  soft,  and  permit  the  red  color  of  the  under- 
lying mucous  membrane  to  shine  through,  have  a 
predilection  for  the  dorsum  of  the  tongue  and  the 
middle  of  the  cheek.  In  the  course  of  time  they 
become  firm  and  sometimes  cornified. 

If  the  spots  grow  they  show  in  most  cases  a 
marked  off  surface  or  area  with  more  or  less  deep 
furrows  and  even  cracks.  It  is  remarkable  how  little 
trouble  is  caused  by  a  very  extensive  and  also  inten- 
sive leukoplakia.  Before  the  patient  is  aware  of  its 
presence  it  can  have  extended  considerably. 

The  course  is  distinctly  chronic:  very  gradually 
and  unnoticed  very  small  spots  of  leukoplakia  develop 
the  larger  discrete  ones. 

The  process  may  stop  at  any  time.  Sometimes  the 
disease  consists  of  only  small  patches  in  the  cheeks, 
but  it  usually  extends  to  some  extent.  The  extension 
and  intensity  of  the  process  need  not  be  in  proportion. 
Small  spots  can  gradually  form  very  marked  thick- 
enings of  the  mucous  membrane  which  are  callous 
and  cracked,  while  the  conjoined  lesions  of  the  mu- 
cous membrane  of  the  tongue  and  cheeks  may  consist 

57 


of  only  a  soft  gray  translucent  thickening  of  the 
epithelium. 

It  is  not  customary,  even  under  the  influence  of 
therapeutic  measures,  for  a  leukoplakia  spot  to  dis- 
appear. Leukoplakia  has  a  special  meaning  in  that 
it  creates  a  certain  local  predisposition  to  carcinoma. 
Many  cases  of  carcinoma  of  the  tongue  have  been 
seen  developing  from  a  leukoplakia.  This  transit 
however  from  leukoplakia  to  carcinoma  is  not  so 
frequent  as  generally  believed.  Cases  of  severe  leu- 
koplakia with  crevices  and  ulcerations  which  have 
been  under  observation  for  a  period  of  years  have 
showTi  no  signs  of  becoming  carcinomatous.  All 
harsh  therapeutic  measures  are  contraindicated. 

The  diagnosis  of  leukoplakia  is  easy  in  typical 
cases,  but  fresh  spots  can  so  resemble  syphilitic  mu- 
cous patches  that  it  is  impossible  to  diagnose  them. 
Occasionally,  in  old  syphilitic  cases,  there  can  appear 
on  the  border  of  the  tongue  isolated  quite  firm,  some- 
times cornified  gray  leukoplakialike  plaques  which 
can  be  extremely  stubborn  to  treatment.  The  tre- 
ponema  pallidum  should  be  looked  for  in  the  lesion 
and  a  Wassermann  reaction  or  luetin  test,  prefer- 
ably both,  should  be  made.  If  all  are  negative  then 
a  diagnosis  by  palliative  therapeutics  must  be  re- 
sorted to. 

Lichen  ruber  planus  may  at  the  first  glance  re- 
semble leukoplakia,  but  by  a  careful  examination  one 
will  never  miss  seeing  the  little  primary  nodules  and 
the  fine  reticular  formation. 


58 


Diseases  Similar  to  the  Lesions  of  Tertiary  Syphilis 
of  the  Mouth 

The  destructive  and  grave  alterations  occasioned 
by  tertiary  syphilis  are  exceedingly  characteristic. 
Tuberculosis  and  carcinoma  maj^  appear  in  a  form 
which  very  closely  resembles  syphilis,  thus  making  a 
differential  diagnosis  very  difficult.  Tuberculosis  of 
the  mouth  can  appear  in  very  many  forms.  It  is  al- 
most always  possible  to  observe  either  the  insignifi- 
cant isolated  spots  or  severe  extensive  processes  de- 
veloping from  the  characteristic  initial  tubercular 
lesion. 

In  the  mouth  there  is  a  single  tubercle  or  a  num- 
ber of  them  may  appear  at  the  same  time.  The  tuber- 
cle grows  more  or  less  slowly,  disintegrates,  under- 
going coagulation  necrosis,  ulcerates  and  discharges 
a  little  caseous  pus. 

The  differential  diagnosis  must  at  times  be  made 
between  lupus  and  other  tubercular  processes  not 
only  of  the  skin  but  of  the  mucous  membrane  of  the 
mouth.  The  difference  between  lupus  and  other  tu- 
bercular processes  in  the  mouth  is  not  marked.  A 
characteristic  skin  lupus,  occurring  in  conjunction 
with  a  suspected  lupus  of  the  mouth,  will  assist  in 
diagnosing  the  latter.  In  the  mucous  membrane  the 
lupus  nodules  are  not  so  characteristic  as  in  the  skin. 
They  have  not  the  same  color  or  consistence ;  the  sec- 
ondary peculiarities — desquamation  and  hyperkera- 
tosis— are  lacking;  and  the  lupus  nodules  in  the  mu- 
cous membrane  ulcerate  much  sooner. 

The  first  lupus  nodules  or  tubercles  give  no 
trouble,  their  ajipearance  is  scarcely  noticed.     Some- 

59 


times  it  is  only  by  accident  that  they  come  to  the 
physician's  attention,  when  they  are  searched  for  in 
the  mouth  of  a  subject  having  hipus  of  the  skin  or 
mucous  membrane  of  the  nose. 

The  mildest  and  most  primitive  form  in  which 
tuberculosis  is  likely  to  occur  in  the  mouth  is  the  ul- 
cerated miliary  tubercle  or  tubercle  granulum.  Each 
ulcer  develops  in  a  tubercular  infiltrate,  which  is  so 
inconspicuous  and  produces  so  little  disturbance  that 
it  may  not  be  observed  or  is  recognized  only  when  the 
disintegration  and  formation  of  the  ulcer  begins. 

The  tubercular  nature  of  even  the  smallest  ulcers 
is  at  once  determined  by  seeing  them  originating  from 
the  miliary  tubercles.  The  form  of  the  tubercular 
ulcer  is  irregular,  with  imdermined  edges  and  a  finely 
granular  uneven  floor  covered  Avith  yellow  or  green- 
ish-yellow pus.  The  form  of  the  ulcers  changes  ac- 
cording to  their  position  and  the  anatomical  struc- 
tures beneath  them.  On  the  mucous  membrane  of  the 
lips  and  checks  their  form  is  round  or  oval  and  they 
are  more  inclined  to  a  superficial  extension.  Ulcers 
of  the  soft  palate  extend  deeplj'  into  the  tissues  and 
those  on  the  tongue  are  long,  indented  and  cleftlike. 

The  tubercular  tissue  in  Mhich  the  ulcers  lie, 
forms  around  them  a  sort  of  reddened  wall  which  is 
slightly  raised  above  the  adjoining  nuicous  mem- 
brane. These  primary  tubercles  and  ulcerations 
grow  slowly  but  steadily,  and  if  appropriate  treat- 
ment does  not  stop  them  more  tubercles  and  a  diffuse 
tubercular  inflammation  (diffuse  tubercle)  develop 
in  their  neighborhood. 

The  tubercular  process  then  extends  either  super- 
ficially, deeply  or  in  both  directions.  The  diffuse 
tubercle  extending  deeply  into  the  tissue  may  form 
ulcers  resembling  those  of  a  gumma  or  carcinoma  or 
it  may  extend  and  form  a  superficial  tuberculosis  of 
the  mucous  membrane  which  corresponds  more  witli 
the  clinical  picture  of  a  tertiary  papular  sy])hilide 
(Fig.  47). 

60 


I 


Tlie  so-called  tubercular  tissue  is  not  always  in- 
clined to  under<ifo  disintfyration.  There  may  be  a 
very  extensive  tubercular  inliltration  of  the  mucous 
membrane  in  which  only  small  or  large  typical  ulcers 
are  seen. 

The  tubercular  tissue  on  the  mucous  membrane  of 
the  palate  can  assuuie  a  very  characteristic  appear- 
ance, viz.:  the  dark  bluish-red  colored  sm-face  of  the 
mucous  membrane  acquires  a  peculiar  velvety  con- 
dition which  is  due  to  tlie  presence  of  a  large  number 
of  exceedingly  delicate  miliary  tubercles.  Such  a 
condition  is  liable  to  be  mistaken  for  lupus  (Fig.  48). 

The  bones  are  also  attacked  in  tuberculosis  as 
well  as  in  syphilis,  but  the  tubercular  process  con- 
trary to  the  sypliilitic  starts  from  the  surface  and 
travels  inward,  so  that  the  corresponding  changes  in 
the  bones  are  superficial  erosions  which  do  not  lead 
immediately  to  the  formation  of  sequestra. 

The  tubercidar  ulcers  of  the  moiith  in  progressive 
phthisis  are  especially  grave.  They  correspond  to 
those  tubercular  ulcerations  which  are  found  so  often 
in  the  respiratory  and  intestinal  tract  of  patients  with 
phthisis  and  are  characterized  by  their  rapid  develop- 
ment, great  destruction  and  the  very  acute  pain  they 
occasion. 

These  ulcers,  when  on  the  tongue  and  lips,  cause 
in  a  short  time  extensive  defects,  although  there  is 
little  tubercidar  infiltration.  The  pus-covered  floor 
and  characteristic  border  clearly  demonstrate  their 
tubercular  nature  (Fig.  49). 

Although  pronounced  peculiarities  exist  in  tuber- 
cular lesions  of  the  mouth,  there  are  a  number  of 
cases  of  tuberculosis  of  tliis  cavity  which  are  very 
difficult  to  distinguish  from  syphilis;  therefore,  be- 
sides the  simple  clinical  consideration  of  the  lesion, 
all  other  allied  conditions  must  be  studied  and  re- 
course had  to  all  available  diagnostic  measures. 
Tubercular  processes,  if  they  have  undergone  any 
extension,  often  have  involved  the  neighboring  lymph 

61 


nodes,  while  in  secondary  and  tertiary  syphilis  the 
lymph  nodes  are  never  so  affected.  The  never-fail- 
ing adenitis  follows  the  chancre  usuaUy  within  a  week 
or  two,  i.e.,  at  a  time  which  plays  no  part  in  the 
tubercular  process. 

Generally  the  period  within  which  the  syphilitic 
and  tubercular  processes  develop}  and  act  their  part 
forms  a  remarkable  distinction  between  the  two  often 
similar  diseases.  Alterations  and  destructions  which 
take  tuberculosis  months  or  even  years  to  bring  about, 
can  be  accomplished  by  syphilis  in  a  few  Aveeks  and 
even  sometimes  in  a  few  days.  Pain  is  often  another 
differential  characteristic.  Small  tubercular  ulcers 
may  be  quite  painful;  whereas  serious,  extensive 
syphilitic  ulcers  will  elicit  only  an  insignificant  local 
com])laint.  The  result  of  therapeutic  measures  may 
enable  us  to  make  a  diagnosis.  The  administration 
of  potassium  iodide  or  mercury  usually  has  some  fa- 
vorable effect  upon  the  syphilitic  process,  while  tu- 
bercular processes  are  not  usually  influenced.  If  the 
diagnosis  by  palliat'we  medication  {diagnosis  ex 
juvantibus)  is  at  all  doubtful,  great  caution  should 
be  exercised  as  it  must  be  remembered  that  syphilis 
can  be  very  refractory  at  times  to  treatment  and  that 
the  administration  of  potassium  iodide  might  occasion 
a  transitory  change  in  the  appearance  of  tubercular 
processes. 

The  diagnosis  ex  jjuvantihus  no  longer  plays  the 
role  it  did  and  for  this  we  are  indebted  to  the  Was- 
sermann  reaction  and  the  detection  by  means  of  the 
microscope,  especially  the  dark-iicld-microscope,  of 
the  treponema  pallidum.  Occasionally  the  diagnosis 
ex  juvantibus  is  made  in  a  doubtful  affection,  for  ex- 
ample, a  tumor  of  the  tongue,  which  is  not  affected 
by  antisyphilitic  treatment,  althougli  the  patient's 
serum  gives  a  positive  Wassermann  reaction.  A 
careful  microscopic  examination  before  prescribing 
antisyphilitic  treatment  miglit  have  determined  the 
presence  of  the   treponema   pallidum,   the  tubercle 

G2 


bacillus,  or  carcinoma  cells  in  the  lesion.  In  such  a 
case  we  are  clcalin<;-  with  a  syphilitic  individual  and  a 
non-syphilitic  affection  of  the  tongue,  possibly  a 
tuberculous  or  cancerous  tumor  of  that  organ. 

[The  tuberculin  reaction,  the  ophthalmic  reaction 
of  Calmette  and  Wolff -Einncr,  the  cuti-reaction  of 
von  Pirquet,  or  the  intradcrmic  reaction  of  Martoux 
are  of  use  in  detecting  tuberculosis.  All  these  reac- 
tions indicate  the  presence  of  tuberculosis,  not  always 
its  localization. — Tr.] 

The  general  reaction  with  tuberculin  indicates  as 
little  for  a  local  tubercular  process  as  the  Wasser- 
mann  does  for  a  local  syphilitic  process.  However, 
by  comparing  the  positive  result  of  the  one  with  the 
negative  result  of  the  other,  important  diagnostic  in- 
formation may  be  obtained. 

[In  conjunction  with  the  Wassermann  reaction, 
the  luetin  cutaneous  reaction,  Avhich  is  said  to  be 
most  constant  and  severe  in  tertiary  affections,  may 
be  used.— Tr.] 

A  local  tuberculin  reaction  however  indicates 
tuberculosis,  but  it  is  not  always  so  distinct  in  the 
mucous  membrane  of  the  mouth,  as  elsewhere  in  the 
body  [e.g.,  about  the  arytenoid  cartilages  in  sus- 
pected tuberculosis  of  the  larj'nx.  The  presence  of 
the  causal  agent  of  the  disease  in  the  lesion  is  de- 
cisive.— Tr.] 

It  is  difficult  to  find  the  tubercle  bacillus  in  tuber- 
cular lesions  of  the  mouth.  The  microscopic  exami- 
nation of  and  inoculation  experiments  with  the  mate- 
rial taken  from  tubercular  ulcers  (except  those  of 
phthisis),  especially  lupus,  do  not  always  prove  the 
presence  or  absence  of  the  tubercle  bacilli  as  they  may 
be  very  few  and  thus  either  escape  observation  or  not 
being  present  in  the  material  used  for  the  inoculation 
experiments  give  a  negative  result.  But  in  tuber- 
cular ulcers  of  phthisis  tubercle  bacilli  are  always  easy 
to  find.  The  presence  of  the  treponema  pallidum  is 
proof  positive  of  syphilis.    The  differential  diagnosis 

63 


of  syphilis  and  tuberculosis  from  the  clinical  signs 
alone  is  usually  not  difficult,  and  cases  are  rare  where 
a  biopsy  or  a  microscopical  examination  are  nec- 
essary. 

The  differential  diagnosis  between  carcinoma  and 
syphilis  is  sometimes  of  the  greatest  importance  in 
order  to  ascertain  whether  or  not  an  operation  shall 
be  undertaken  to  save  the  patient's  life,  or  again  to 
determine  if  the  lesion  may  be  removed  in  a  short 
time  by  suitable  general  treatment  instead  of  by  a 
dangerous  and  mutilative  operation.  These  two  dis- 
eases have  so  many  features  in  common  that  every 
diagnostic  measure  must  be  resorted  to  in  order  to 
differentiate  them,  and  the  diagnosis  is  made  at  times 
solely  through  a  biopsy. 

Carcinoma  (Fig.  50)  can  at  any  stage  resemble 
a  syphilitic  manifestation,  and,  like  syphilis,  shows  a 
predilection  for  the  lip,  tongue,  and  tonsils.  In  the 
earliest  stage  it  appears  as  an  insignificant  infiltrate, 
a  small  ulcer  or  little  wart  with  nothing  characteris- 
tic about  it.  It  grows  very  slowly  at  first;  for 
months  it  undergoes  no  appreciable  change  and 
causes  no  inconvenience.  As  it  grows  its  surface  be- 
comes eroded,  the  epidermis  desquamating  com- 
pletely, and  a  surrounding  surface,  resembling  a  ram- 
part, which  bleeds  easily  and  has  an  edge  as  hard  as 
cartilage,  gradually  rises  above  the  surrounding 
tissues.  Tlie  erosion  becomes  a  penetrating  ulcer, 
the  infiltrate  spreads  in  every  direction,  and  the 
neighboring  lymph  nodes  begin  to  be  involved.  The 
floor  of  the  ulcer  is  covered  with  yellow,  greenish  or 
grayish  yellow  pus  or  with  a  dirty,  bloody  mass. 
Very  often  one  perceives  on  the  surface  of  the  ulcer, 
especially  the  edges,  small  gray  bodies,  the  epithe- 
lial pearls,  which  can  l)c  pressed  from  the  tissue. 
Often,  through  extensive  ulceration,  the  process  loses 
its  tumor  characteristic.  Tlie  degeneration  is  such  a 
marked  feature  that  at  times  there  remains  of  the 
original  neoplasm  only  a  firm,  slightly  raised  edge. 

64 


PREFACE 


CONTENTS 


Thi  Cauie  OF  Syphilis— New  Light  on  Parasyphilitic  Disease 
— The  Treatment  of  Syphilis  with  Salvarsan— Com- 
bined Treatment  of  Syphilis  with  Salvarsan  and 
Mercury. 


^    J         -rn  THE  SALVARSAN  TREATMENT 

Urder  r  orm  ok  syphilis  in  private  practice 

By   Stopford-Tayliir  and  MacKenna 

To  REBMAN  COMPANY 

141  W.  36tli  Street,  New  York 

Please  enter  my  name    as  a   Subscriber  to  the  above  work   at 

$1.50  bound  in  cloth,  for  which  I  enclose 

Name 

Address 

W»-27-»ii-H-C.  H. 


We  believe  that  the  time  is  now  ripe  for  us  to  put  on 
record  the  impressions  we  have  gained,  and  the  conclu- 
sions we  have  arrived  at  after  more  than  three  years  use 
of  Salvarsan  in  the  treatment  of  Syphilis.  All  the  work 
on  which  our  conclusions  are  based  has  been  done  in 
our  private  practice,  where  we  have  been  able  to  follow 
out  the  after-histories  of  the  patients.  We  believe  that 
anyone  who  reads  the  following  pages  will  be  convinced, 
as  we  are,  of  the  immense  benefit  conferred  on  the 
human  race  by  Ehrlich's  great  discovery;  and  of  its  unique 
efficacy    in    controlling    one    of    the    most     devastating  3 

plagues  that  ever  ravaged  mankind. 


1 


CLOTH  $1.50  NET 

The  Salvarsan  Treatment 

OF  SYPHILIS    IN  PRIVATE    PRACTICE 

WITH   SOME   ACCOUNT  OF   THE   MODERN 
METHOD   OF   DIAGNOSIS 

GEORGE  STOPFORD-TAYLOR 

M.D.,  M.R.C.S. 


ROBERT  WILLIAM  MacKENNA 

M.A.,  M.D..  B.Ch. 

Physician  to  the  Liverpool  Skin  Hospital 

Illustrated 


>  ) 


.  iT'.Ttl        't 


NEW  YORK 

REBMAN    COMPANY 

HERALD  SQUARE   UUU.DING 

141-145  WEST  36ili  STREET 


i;! 


t  * 


At  other  times  the  neoplasmic  tissue,  instead  of 
undergoing  degenerative  changes,  tends  to  increase, 
and  as  a  result  large  irregular  tumors  are  formed, 
with  a  surface  which  bleeds  easily,  is  uneven,  granu- 
lar, and  covered  with  pus  or  sanious  material.  The 
sad,  final  picture  of  carcinoma  is  well  known;  the  ter- 
rible destruction,  the  metastases,  the  cachexia  and 
death. 

The  differential  diagnosis  of  carcinoma  and  chan- 
cre is  not  easy;  consequently,  it  is  most  important  to 
avail  one's  self  of  all  possible  means  of  diagnosis. 
Carcinoma  can  resemble  a  yrimarii  sypJiilitic  lesion 
not  only  in  its  initial  stages,  when  there  is  only  a 
slight  infiltration,  but  also  when  it  becomes  eroded 
or  indurated  or  even  idcerated. 

The  facts,  that  carcinoma  is  usually  a  disease  oc- 
curring after  middle  life,  that  the  chancre  is  usually 
contracted  earlier  in  life,  and  that  their  predilection 
for  localizing  themselves  is  different,  are  not  im- 
portant points  in  diagnosis.  However,  it  is  well  to 
remember  that,  on  the  lip,  the  usual  situation  of  a 
chancre  is  at  the  centre,  of  carcinoma  toward  the 
side;  that  a  chancre  is  rarely  seen  upon  the  base  or 
under  surface  of  the  tongue,  and  that  a  chancre  on 
the  gums,  cheeks  or  palate  is  less  frequent  than  car- 
cinoma. 

The  difference  in  the  clinical  picture  and  course 
of  these  two  diseases  is  very  important  so  long  as  the 
epidermis  is  intact;  the  character  of  the  periphery  of 
the  lesion  is  especially  noteworthy  in  diagnosis.  The 
eroded  surface  of  the  chancre  is  flat,  smooth,  faintly 
shining,  and  exudes  a  clear  serum,  while  the  rough, 
uneven  surface  of  the  eroded  carcinoma  bleeds  easily 
and  pus  exudes.  In  the  event  of  ulceration  the  sur- 
face of  the  chancre  is  not  so  uneven,  corroded  and 
anfractuous  as  in  carcinoma,  and  the  bleeding  and 
exudation  of  pus  is  less,  but  there  is  a  greater  exudate 
of  serum.  The  ulcerated  chancre  never  has  a  sanious 
exudate,  which  always  appears  early  in  carcinoma, 

65 


as  evidenced  by  the  bad  taste  in  the  mouth  and  the 
foetor.  The  primary  lesion  never  extends,  there  is 
no  limit  to  the  extension  of  carcinoma.  The  epithelial 
pearls  in  the  border  of  the  tumor  are  pathognomonic 
of  carcinoma.  The  pain,  which  is  almost  always  ab- 
sent, in  even  very  extensive  primary  lesions,  occurs  in 
the  earliest  stages  of  carcinoma  and  is  very  severe. 
The  course  of  the  two  diseases  is  very  striking.  The 
chancre  grows  quickly.  It  would  take  at  least  several 
months  for  a  carcinoma  to  acquire  the  size,  a  small 
erosion  does  in  two  or  three  weeks.  The  adenopathy 
of  the  adjoining  lymph  ganglia  occurs  very  early 
with  the  initial  lesion;  it  takes  but  a  few  days  to  de- 
velop, and  is  never  absent.  A  carcinoma  can  exist 
for  a  long  time  before  any  metastasis  in  the  neighbor- 
ing lymph  nodes  is  noticed.  Finally,  the  secondary 
manifestations  of  syphilis  never  fail  with  the  primary 
lesion,  although  occasionally  they  may  be  very  in- 
distinct and  tluis  overlooked. 

The  WasHcnnann  reaction  remains  negative  up 
to  about  the  seventh  week  after  the  appearance  of 
the  chancre.  It  is  usually  easy  to  find  the  treponema 
pallidum  in  the  exudate  from  the  chancre,  imless  the 
chancre  is  ulcerated.  In  ulcerated  chancres  where 
there  is  an  exudation  of  pus  it  is  sometimes  difficult 
to  find  the  causal  agent. 

The  lesions  of  secondary  syphilis  of  the  mouth, 
especially  when  they  are  ulcerated,  can  occasionally 
resemble  carcinoma,  but  they  develop  faster  and  have 
not  the  characteristic  firm  base  of  the  latter.  The 
syphilitic  lesions  are  multiple,  the  carcinoma  always 
single.  Other  manifestations  of  syphilis  accompany- 
ing the  lesion  under  question  help  the  diagnosis.  Ul- 
cerated lesions  of  malignant  syphilis  are  seldom  sin- 
gle, and  the  diagnosis  is  sometimes  difficult,  in  that  it 
is  not  easy  to  find  the  treponema  pallidum  in  these 
lesions. 

The  treponemata  pallida  have  been  found  in  gum- 
mata,  but  as  there  are  so  few  of  them  in  these  lesions 

66 


it  is  difficult  to  find  them.  This  is  especially  unfortu- 
nate, as  a  number  of  diagnostic  features  wliidi  are 
present  in  the  primary  and  secondary  manifestations 
of  syphilis  are  wanting  in  the  gumma,  therefore  the 
differential  diagnosis  of  gumma  and  carcinoma, 
which  is  most  important,  is  sometimes  very  difficult. 
A  study  of  the  course  of  the  two  processes  is  helpful 
in  making  a  differential  diagnosis.  The  gumma  can 
grow  very  fast,  but  may  at  times  develop  slowly.  It, 
however,  develops  much  more  slowly  than  the  chan- 
cre. An  involvement  of  the  neighboring  lymph 
nodes  is  always  absent  with  the  gumma,  but  is  always 
an  early  i)athognomonic  sign  with  the  initial  lesion. 
The  gumma  can  extend  and  produce  as  much  de- 
struction as  carcinoma,  but  here  the  absence  of 
adenopathy  with  the  gumma  is  a  help  in  diagnosis. 
The  serous  exudate  is  absent  on  the  eroded  and  ul- 
cerated surfaces  of  the  carcinoma  and  gumma. 
Where  no  secondary  manifestations  follow  the  sus- 
pected primary  lesion  the  diagnosis  of  carcinoma  is 
favored. 

The  gumma  usually  gives  a  positive  Wassermann 
reaction,  but  there  are  tertiary  processes  where  the 
reaction  may  be  negative,  and  it  is  possible  that  a 
subject  with  latent  syphilis  giving  a  positive  Was- 
sermann reaction  can  also  be  afflicted  with  carcinoma. 
[NogucJii's  luetin  reaction  can  be  used  in  conjunction 
with  the  Wassermann  reaction  in  diagnosing  tertiary 
syphilitic  lesions. — Tr.]  In  cases  where  there  seems 
to  be  danger  in  waiting  even  a  week  to  determine  the 
condition,  a  biopsy  should  be  made  to  find  out  the 
nature  of  the  disease. 


67 


1 


PLATE  I 

Figure  1.— Chancre  of  the  Upper  Lip 
(Chancrous  Erosion) 


Figure  1.— Chancre  of  the  Upper  Lip 
(Chancrous  Erosion). 

On  the  right  side  of  the  upper  lip  there  was  an 
eroded  spot  about  1  em  in  diameter.  Its  surface 
had  a  faint  lustre,  was  darker  than  the  surrounding 
normal  mucous  membrane,  and  upon  pressure  a  clear 
serum  exuded.  The  induration  at  the  base  of  the 
erosion  was  of  small  extent  and  depth,  and  on  pal- 
pation it  felt  almost  as  hard  as  cartilage.  The  right 
submaxillary  ganglia  were  swollen,  but  not  painful, 
and  were  movable  luider  the  skin.  In  the  exudate 
from  the  chancre  numerous  treponemata  pallida  were 
found. 

The  patient,  who  was  twenty  years  old,  also  had 
a  syphilitic  angina  and  a  light  roseola.  The  Wasser- 
mann  reaction  was  positive. 


70 


Plate  I.     Fig.  1 


PLATE   II 
Figure  2.— Two  Chancres  of  the  Lower  Lip 


Figure  2.— Two  Chancres  of  the  Lower  Lip 

On  either  side  of  the  median  line  there  was  a 
round  elevated,  eroded,  partly  ulcerated  chancre  with 
an  encrusted  surface.  When  the  crusts  were  detached 
a  bloody  serum  exuded  in  which  numerous  trepone- 
mata  pallida  were  found.  Marked  adenopathy  of 
the  submaxillary  lymph  nodes  on  each  side.  The 
tongue  was  coated  and  there  were  a  number  of  ellip- 
tical, sometimes  confluent  spots — mucous  patches  of 
the  tongue — with  a  smooth  surface. 

The  patient,  a  young  woman,  having  chapped  lips 
was  infected  by  a  kiss  during  the  carnival  in  Cologne. 
She  also  had  a  miliary  syphilide,  a  syphilitic  angina, 
general  adenopathy,  condylomata  lata  about  the  geni- 
tals, an  impetigo  capitis  and  psoriasis  palmaris  et 
plantaris. 

TJie  Wassermann  reaction  was  positive. 


74 


Plate  11,     Fig.  2 


PLATE   III 
Figure  3.— Chancre  of  the  Tongue 


Figure  3.— Chancre  of  the  Tongue 

On  the  left  side  of  the  tongue  there  was  an  ellip- 
tical tumor  about  1.5  cm  long  and  1  cm  wide,  which 
involved  the  musculature.  It  felt  firm  and  gradually- 
merged  with  the  surrounding  normal  tissue.  Its 
browTiish  red  surface  was  eroded  and  there  was  a 
furrow  running  through  it.  The  surrounding  tissue 
was  not  congested.  The  submaxillary  lymph  nodes 
on  both  sides  were  involved.  On  pressure  serum  ex- 
uded from  the  lesion,  in  which  treponemata  pallida 
were  found.  The  patient  did  not  know  how  he  ac- 
quired the  lesion,  but  stated  he  had  sexual  inter- 
course eight  weeks  previously.  Besides  a  slight 
syphilitic  angina  there  were  no  other  signs  of  syphilis. 
The  Wassermann  reaction  was  positive. 


78 


Plate  III.     Fig.  3 


r 


> 


/ 


PLATE   IV 

Figure  4.— Syphilitic  Erythema  of  the 
iVIucous  IVIembrane  off  the  Mouth 


Figure  4.— Syphilitic   Etythema  of  the 
Mucous  IVIembrane  of  the  Mouth 

Red  spots,  with  darker  borders,  somewhat  an- 
nular in  form,  are  seen  on  the  mucous  membrane  of 
both  sides  of  the  upper  hp.  They  are  not  eroded  and 
are  not  characteristic  of  syphihs.  They  may  corre- 
spond to  the  roseola  on  the  skin,  and  are  the  mildest 
form  of  lesion  involving  the  buccal  mucous  membrane 
in  the  secondary  period  of  syphilis.  The  lesions  pic- 
tured accompanied  the  secondary  manifestations  fol- 
lowing a  chancre  on  the  finger  and  disappeared  in 
a  few  days,  after  the  disease  had  been  treated  by 
inunctions  of  mercury. 


82 


Plate  IV.     Fig.  4 


PLATE  V 

Figure  5.— Erosive  Mucous  Patclies  of  tlie 
Lower  Lip  and  Condylomata  Lata  of  tlie 
Naso-Labiai  Folds 


Figure  5.— Erosive  Mucous  Patches  of  the 
Lower  Lip  and  Condylomata  Lata  of  the 
Naso-Labiai  Folds 

On  the  vermilion  of  the  lower  lip  is  a  small  red 
spot  beginning  to  erode  at  the  centre.  Behind  it,  on 
the  mucous  membrane  of  the  lip,  is  a  small  eroded 
papule  covered  with  a  layer  of  yellowish  fibrin. 
Neither  is  absolutely  characteristic  of  syphilis.  The 
yellow  erosion  resembles  greatly  an  aphthous  ulcer  of 
the  mouth,  but  there  is  no  pain  or  surrounding  in- 
flammatory reaction.  The  diagnosis  of  these  papules 
(mucous  patches),  when  they  are  the  only  manifes- 
tations in  a  relapsing  syphilis,  is  most  important,  as 
the  patient  often  does  not  know  he  has  them.  The 
treponema  })allidum  was  easily  found  in  them. 

In  this  case,  however,  other  manifestations  showed 
themselves,  e.g.,  condylomata  lata  in  the  naso-labial 
folds,  which  are  well  developed,  ulcerated,  and  en- 
crusted. A  slight  congestion  and  insignificant  infil- 
tration of  the  skin  in  this  region  is  suspicious,  but  it 
is  not  to  l)e  forgotten  that  a  similar  infiltrate  may 
occur  with  seborrhoea. 


86 


Plate  V.     Fig.  5 


I 


PLATE   VI 

Figure  6.— Erosive  IViucous  Patciies  of  tlie 
Upper  Lip  and  Tongue 


Figure  6.— Erosive  Mucous  Patches  of  the 
Upper  Lip  and  Tongue 

A  slightly  elevated  eroded  mucous  patch  was  seen 
upon  the  right  side  of  the  upper  lip  and  on  the  tip 
of  the  tongue.  Accompanying  them  was  a  roseola, 
syphilitic  angina,  impetigo  capitis,  and  condylomata 
lata  about  the  genitals.  Spirochstfe  were  found  in 
them  and  the  Wosscrmann  reaction  was  positive. 

Alone,  these  lesions  are  not  characteristic  of  syphi- 
lis, and  might  be  mistaken  for  a  superficial  burn,  cor- 
rosion, or  bite. 


90 


Plate  VI.     Fig.  6 


PLATE  VII 

Figure  7.— Hypertrophied  Mucous  Patches 
of  the  Tongue  and  Lips 

Figure  8.— Papuio-Ulcerated  Syphilide  off 
the  Lips  and  Tongue  (Uicerated  iVIucous 
Patches) 


Figure  7.— Hypertrophied  Mucous  Patches 
of  the  Tongue  and  Lips 

On  the  mucous  membrane  of  the  tongue  and 
lower  lip  are  raised,  irregular,  bow-shaped,  tumorlike, 
circumscribed  mucous  patches,  and  passing  through 
them  here  and  there  are  deep  ulcerated  furrows.  Their 
surfaces  are  white  or  yellowish-gray  and  in  some 
places  there  is  a  thickening  of  the  epithelium. 

These  lesions  were  the  only  symptoms  of  syphilis 
which  was  contracted  seven  years  previously  and 
which  had  been  insufficiently  treated.  Eating  and 
speaking  were  but  slightly  affected. 

During  a  little  more  than  a  year  the  lesions  grad- 
ually developed  into  their  present  condition.  The 
patient  was  sixty  years  old.  Prompt  improvement 
followed  antisyphilitic  treatment. 

Figure  8.— Papulo-Ulcerated  Syphiiide  of 
the  Lips  and  Tongue  (Ulcerated  IVIucous 
Patches) 

On  the  left  side  of  the  lower  lip  is  an  elliptical 
raised  gray  mucous  patch,  with  bow-shaped  ulcerated 
edges  and  on  its  surface  are  ulcerated  furrows.  On 
the  upper  lip  are  two  ulcerated  excoriations  with  a 
gray  border.  On  either  side  of  the  frenum  of  the 
tongue  is  a  flat  elliptical  ulceration  with  a  yellowish- 
gray  coating. 

The  patient,  a  waiter,  twenty-eight  years  old,  had 
syphilis  for  nine  months.  The  only  treatment  re- 
ceived consisted  of  potassium  iodide  internally  and 
local  treatment  of  the  lesions.  There  was  also  an 
indurated  scar  on  his  penis,  general  adenopathy  and 
a  syphilitic  angina.  The  Wasscrmann  reaction  was 
positive. 

Under  inunctions  and  painting  of  the  lesions  with 
bichloride  of  mercury  (2%)  the  manifestations  dis- 
appeared. 

94 


Plate  VII.     Figs.  7,  8 


PLATE  VIII 

Figure  9.— Ulcerated  Syphilide  of  the  Lips 
(Ulcerated  IMucous  Patciies) 


Figure  9.— Ulcerated  Syphilide  of  the  Lips 
(Ulcerated  Mucous  Patches) 

The  upper  and  lower  lips  are  inflamed  and  swol- 
len. On  the  actively  congested  mucous  membrane  are 
several  ulcerations.  On  the  left  side  of  the  upper  lip 
is  an  ulcer  with  a  concave  floor  covered  with  an  ad- 
herent yellow  coating  and  with  dried  somewhat  hem- 
orrhagic crusts  on  its  border. 

On  the  lower  lip  near  the  right  angle  of  the  mouth 
the  mucous  membrane  is  puff"ed  up  and  covered  with 
a  slight  grayish  coating.  Irregular,  hollowed  out 
and  furrowlike  ulcers  cross  it.  The  ulcers  are  painful. 
On  the  mucous  membrane  of  the  gums  (above)  there 
is  seen  a  flat  ring-shaped  mucous  patch. 

The  patient  had  syphilis  for  four  years,  which  had 
been  insufficiently  and  irregularly  treated.  The  ul- 
cers in  the  mouth  existed  about  four  weeks.  They 
might  possibly  be  mistaken  for  tuberculosis,  but  their 
short  duration,  their  gray  borders  and  the  presence 
of  a  characteristic  syphilitic  angina  indicated  syphilis. 
The  margins  of  these  ulcers  do  not  show  the  finely 
serrated  or  cutout  borders  which  are  to  be  observed 
in  tubercular  ulcerations.  The  tongue  of  this  patient 
is  shown  in  Fig.  13. 


m 


Plate  VIII.     Fig.  9 


PLATE   IX 

Figure  10.— An  Ulcerated  Annular  Syphilide 
of  the  Lower  Lip  Resembling  a  Serpigi- 
nous Ulcer 


Figure  10.— An  Ulcerated  Annular  Syphilide 
of  the  Lower  Lip  Resembling  a  Serpigi- 
nous Ulcer 

On  the  vermilion  of  the  lower  lip  is  a  ring-shaped 
ulcer,  having  a  transverse  diameter  of  about  2  to  3  cm. 
The  ulcer  is  quite  narrow,  comparatively  deep,  with 
precipitous  walls  and  its  floor  is  covered  with  pus. 
In  addition  to  this  lesion  there  was  a  suspicious  an- 
gina, a  leukoderma  colli  and  a  positive  W assermann 
reaction.  (The  annular  ulcer  does  not  develop  into 
a  serpiginous  idcer  by  peripheral  growth,  as  tlte 
centre  is  not  made  up  of  scar  tissue,  but  it  is  thought 
that  the  border  of  a  papular  infiltrate  has  undergone 
ulceration.) 


102 


Plate  IX,    Fig.  10 


PLATE  X 

Fig.  11.— Opaline   iVIucous    Patciies  of  the 

Tongue 

Fig.  12.— Papulo-Uicerated  Sypliilide  of  the 

Tongue 


Figure    11.  — Opaline    IVIucous   Patciies    of 
the   Tongue 

To  the  right  of  the  tip  of  the  tongue  is  a  slightly 
elevated  mucous  patch  with  a  soft  gray  covering,  as 
if  it  had  been  painted  with  a  weak  solution  of  silver 
nitrate.  On  the  base  of  the  tongue  is  a  circular, 
raised,  rampartlike  mucous  patch  with  a  depression 
in  its  centre  and  surrounded  by  a  shallow  groove. 

Syphilis  had  been  contracted  eight  weeks  previ- 
ously. The  genital  chancre  was  still  present,  together 
with  an  ulcerated  syphilide  of  the  skin,  a  syphilitic 
angina,  and  an  alopecia  diffusa. 


Figure   12.— Papulo-Uicerated   Syphilide  of 
the  Tongue 

This  case  shows  a  marked  superficial  and  paren- 
chymatous involvement  of  the  tongue.  The  entire 
tongue  is  swollen  and  congested.  The  nmcous  mem- 
brane is  smooth,  excepting  where  the  numerous  irreg- 
ular flat  mucous  patches  and  ulcers  are  situated.  The 
ulcers  are  round,  except  on  the  tip  of  the  tongue 
where  they  have  run  together  and  become  shaped  like 
the  figure  8.  The  preexisting  furrows  of  the  tongue 
have  become  especially  marked  by  the  infiltration. 

The  patient,  who  was  twenty-five  years  old, 
through  deficient  treatment,  found  himself  in  this 
condition  after  the  disease  had  existed  for  one  year. 
In  addition  to  these  lesions  there  was  an  extensive 
deeply  ulcerated  syphilide  of  the  skin  and  a  syphilitic 
angina. 

Under  Zittman  and  calomel  injections  the  local 
manifestations  of  the  disease  and  the  general  condi- 
tion of  the  patient  rapidly  became  better. 


106 


Plate  X.     Figs.  11,  12 


PLATE  XI 

Fig.  13.— Glossitis  Syphilitica  (Syphilitic 
Glossitis) 

Fig.  14.— Ulcerated  Mucous  Patches  of 
the  Tongue 


Figure  13.— Glossitis  Syphilitica  (Syphilitic 
Glossitis) 

The  entire  tongue  is  infiltrated  and  swollen,  and 
its  movement  is  hindered.  The  hypertrophied  papil- 
la give  the  surface  a  rough  appearance.  In  the  mid- 
dle of  the  tongue,  embedded  in  an  especially  firm  in- 
filtrated tissue,  are  several  star  and  V-shaped  furrows 
about  1  cm  deep.  They  are  not  the  result  of  ulcera- 
tions, but  are  the  original  furrows  of  the  tongue  which 
through  the  parenchymatous  infiltration  have  become 
marked. 

This  case  must  be  looked  upon  as  a  deep  papular 
infiltrate  passing  into  a  chronic  parenchymatous  and 
interstitial  inflammation  with  final  atrophy  of  the 
tongue.  Such  cases  do  not  appear  in  the  secondary 
period  of  syphilis,  but  in  syphilis  of  long  standing  and 
in  neglected  cases.  This  case  was  of  four  years' 
duration,  and  had  received  insufficient  treatment. 
Compare  Fig.  9. 


Figure  14.— Ulcerated  Mucous  Patches 
of  the  Tongue 

The  entire  tongue  is  intensely  red  and  swollen. 
The  right  half  of  the  tongue  is  almost  covered  with 
mucous  patches,  more  or  less  deeply  ulcerated  and 
covered  with  yellow  fibrinous  membranes.  The  le- 
sion nearest  the  tip  of  tlie  tongue  is  undergoing  cen- 
tral softening  and  is  about  to  rupture.    On  the  left 

111 


side  of  the  tongue  is  a  typical,  faintly  shining,  smooth 
mucous  patch. 

The  patient  was  twenty-four  years  old,  and  in 
addition  to  the  above  lesions  had  a  chancre  of  the 
anus,  condylomata  about  the  genitals,  a  macular  erup- 
tion, and  mucous  patches  of  the  mucous  membrane  of 
the  cheeks. 

These  deep  ulcers  of  the  tongue  occurred  in  the 
early  secondary  period  of  syphilis,  eight  to  ten  weeks 
after  the  chancre.  This  is  not  usual,  and  this  case  is 
to  be  looked  upon  as  having  somewhat  the  character 
of  a  malignant  syphilis. 

Some  months  after  the  disappearance  of  the  first 
manifestations  of  the  disease,  which  was  obtained  by 
mercurial  inunctions,  the  patient  returned  with  a  re- 
lapse indicated  chiefly  by  a  severe  rupial  syphilide. 


112 


Plate  XI.     Figs.  13,  14 


PLATE  XII 

Fig.  15.— Angina  Syphilitica  (Syphilitic 
Angina) 


Figure  15.— Angina  Syphilitica  (Syphilitic 
Angina) 

In  this  case  there  is  to  be  seen  on  the  reddened, 
oedematous  and  swollen  mucous  membrane  of  the  isth- 
mus of  the  fauces,  soft  palate,  and  uvula,  a  number  of 
shining  soft  gray,  bow-formed  or  round  mucous 
patches  which  look  somewhat  as  if  milk  had  been 
poured  on  the  surface  of  the  mucous  membrane.  This 
is  a  mild  form  of  syphilitic  angina,  and  when  examined 
in  an  unfavorable  light  might  be  mistaken  for  a 
simple  catarrhal  angina.  On  the  middle  of  the  tongue 
is  a  flat,  round  or  somewhat  star-shaped  ulceration. 


116 


Plata  XII.    Fig.  15 


PLATE  XIII 

Fig.  16.— Papules  of  the  Soft  Palate  and 

Uvula 


Figure  16.— Papules  of  the  Soft  Palate 
and  Uvula 

On  the  mucous  membrane  of  the  soft  palate  and 
uvula  is  a  slightly  raised  bluish-gray-red  papular  in- 
filtrate, which  causes  a  thickening  of  the  free  border 
of  these  structures.  There  is  also  a  soft  darker  red 
border  separating  this  infiltrate  from  the  surrounding 
normal  tissue.  The  tonsils  are  not  swollen  and  can- 
not be  seen.  This  is  a  mild  form  of  papular  angina. 
The  patient,  who  was  in  his  eighth  week  after  infec- 
tion, had  condylomata  lata  on  his  scrotum,  and  his 
chancre  had  not  disappeared. 

These  manifestations  in  the  mouth  quickly  dis- 
appeared after  inunctions  were  begun. 


120 


Plate  XIII.     Fig.  16 


PLATE  XIV 

Fig.  17.— Annular  Syphilide  of  the  Mucous 
Membrane  of  the  Soft  Palate,  Uvula  and 
Pillars  of  the  Fauces 


Figure  17.— Annular  Syphilide  of  the  Mucous 
Membrane  of  the  Soft  Palate,  Uvula  and 
Pillars  of  the  Fauces 

The  mucous  membrane  of  the  soft  palate,  u\aila 
and  pillars  of  the  fauces  is  quite  red  and  covered  with 
numerous  ring-formed  gray  mucous  patches  which 
tend  to  run  together,  forming  a  network.  There  are 
also  some  gray  mucous  patches  on  the  tongue.  There 
is  a  very  red,  narrow  border  which  forms  quite  a  sharp 
line  of  demarcation  between  the  healthy  and  diseased 
mucous  membrane.    The  tonsils  are  not  involved. 

This  manifestation  existed  some  months,  with 
very  slight  skin  manifestations,  following  a  chancre 
of  the  upper  lip.  The  case  had  been  insufficiently 
treated. 


124 


Plate  XIV.     Fig.  17 


PLATE  XV 

Fig.  18.— Hypertrophied  Mucous  Patch  of 
the  Soft  Palate  and  Uvula 


Figure  18.— Hypertrophied  Mucous  Patch 
of  the  Soft  Palate  and  Uvula 

A  markedly  hypertrophied  mucous  patch  involves 
the  base  of  the  uvula,  the  edge  of  the  velum  palati 
and  the  right  anterior  pillar  of  the  fauces.  This  ap- 
pears as  a  wliite  tumor  upon  an  actively  congested 
mucous  membrane. 

The  lesion  extended  over  the  enlarged  tonsil  to 
the  right  posterior  pillar  of  the  fauces  (not  shown 
in  the  plate). 

The  patient  at  this  time  was  thirtj'  years  old,  the 
disease  had  been  contracted  eight  months  previously, 
and  about  sixteen  inunctions  of  mercury  had  been 
given.  A  leucoderma  colli  was  present  and  the  Was- 
sermann  reaction  was  positive. 


128 


Plate  XV.     Fig.  18 


PLATE  XVI 

Figure  19.— Angina  Ulcerosa  (Ulcerated 
Syphilitic  Angina) 


Figure  19.— Angina  Ulcerosa  (Ulcerated 
Syphilitic  Angina) 

Congestion  and  oedema  of  the  mucous  membrane 
of  the  fauces,  and  especially  of  the  uvula,  are 
to  be  seen.  In  the  middle  of  the  soft  palate, 
above  the  uvula,  there  are  small  flat  ulcerations 
with  a  grayish  coating.  The  nuicous  mem- 
brane, to  the  right  of  the  uvula,  is  puffed  up  and  at 
the  right,  between  the  anterior  and  posterior  pillars 
of  the  fauces,  is  a  flat  ulcer  covered  with  a  dirty  gray- 
ish-yellow membrane,  which  extends  to  the  posterior 
pharyngeal  wall.  The  edges  of  the  anterior  and  pos- 
terior pillars  of  the  fauces  have  been  destroyed  by  the 
ulcerative  process. 

The  patient,  who  had  contracted  syphilis  three 
years  before,  had  taken  insuflicient  treatment.  In 
addition  to  the  ulcerated  angina  a  pustular  syphilide 
was  present,  and  the  Wassermann  reaction  was  posi- 
tive. 


182 


Plate  XVI.     Fig.  19 


PLATE  XVII 

Figure  20.— Circinate  Mucous  Patches 
About  the  Mouth  and  Nose 


Figure  20.— Circinate  Mucous  Patches 
About  the  Mouth  and  Nose 

About  the  mouth  is  a  group  of  shghtly  raised 
brownish-red-colored,  ring  and  garland-formed  mu- 
cous patches  with  slightly  desquamating  surfaces. 
Their  situation  about  the  mouth  is  characteristic  of 
syphilis  and  an  important  sign  in  its  diagnosis.  The 
circinate  mucous  patch  has  a  special  predilection  for 
this  locality. 

Sometimes  a  differential  diagnosis  must  be  made 
between  this  affection  and  herpes  tonsurans.  The 
almost  uniform  size  of  the  rings,  the  slight  desquama- 
tion and  the  relatively  firm  infiltration  help  to  dis- 
tinguish this  affection  from  herpes  tonsurans.  In 
herpes  tonsurans  the  fungi  and  in  these  mucous 
patches  the  treponemata  pallida  are  easily  found. 

In  this  case  there  were  condylomata  about  the 
genitals  and  a  papulo-squamous  eruption. 


136 


Plate  XVII.     Fig.  20 


PLATE  XVIII 

Figure  21.— Gummatous  Ulcers  of  the 
Mucous  Membrane  of  the  Hard  Palate 


Figure  21.— Gummatous  Ulcers  of  the 
Mucous  Membrane  of  the  Hard  Palate 

The  entire  mucous  membrane  of  the  hard  palate  is 
actively  inflamed,  (Edematous,  swollen  and  dark  red 
in  color.  Upon  it  are  seen  numerous  long,  bow- 
shaped  superficial  ulcers  covered  with  a  grayish- 
yellow  membrane.  In  places  the  ulcers  run  together 
and  form  a  reticulated  ulcer.  The  ulcers  have  re- 
sulted from  a  central  necrosis  of  protruding  infil- 
trates. 

Eighteen  years  since,  the  patient  had  a  chancre 
and  bubo ;  had  received  some  inunctions,  but  since  then 
had  taken  no  treatment.  These  ulcers  developed 
within  four  months  before  the  existence  of  the  con- 
dition, seen  in  the  picture,  and  a  sequestrum  had  is- 
sued from  his  nose  within  a  week  before  the  picture 
was  taken.    The  Wasscrmann  reaction  was  positive. 

Notwithstanding  the  involvement  of  tlie  bones  of 
the  nose  in  this  case,  these  ulcers  originated  in  the 
mucous  membrane  and  not  from  the  periosteum  or 
bone.  The  appearance  of  these  ulcers  resemble  some- 
what tubercular  ulcers  of  the  mucous  membrane. 

The  tubercular  ulcers  are,  however,  more  hollowed 
out  and  serrated  with  sharper  and  more  precipitous 
walls  and  are  accompanied  by  evidence  of  necrosis  of 
the  tubercules — some  of  which,  still  intact,  may  per- 
haps be  seen  surrounding  the  ulcers.  Tubercular 
ulcers  never  reach  such  an  extension  in  four  months. 
Compare  Fig.  47. 


140 


Plate  XVIII.     Fig.  21 


PLATE  XIX 

Figure  22.— Tertiary  Sypliiiis,  Perforation 
of  the  Hard  Palate,  Periostitis  of  tlie 
Processus  Aiveolaris 


Figure  22.— Tertiary  Sypiiilis,  Perforation 
of  the  Hard  Palate,  Periostitis  of  tlie 
Processus  Alveolaris 

The  patient,  thirty-two  years  old,  had  contracted 
syphilis  ten  years  previously.  She  had  received  inade- 
quate treatment  and  had  aborted  several  times.  In 
the  eighth  year  of  the  disease  there  vi^as  swelling  of  the 
hard  palate  followed  by  perforation.  An  extensive 
gummatous  destruction  of  the  bones  of  the  nose,  per- 
foration of  the  hard  palate  and  ozoena  caused  her  to 
seek  treatment. 

Under  an  energetic  treatment  with  potassium  io- 
dide and  mercury  these  manifestations  subsided.  Sir 
months  later  there  appeared  a  new  lesion  of  the  nose, 
and  a  periostitis  of  the  alveolar  process  of  the  maxil- 
lary bones,  which  led  to  the  formation  of  a  sequestrum 
containing  three  incisor  teeth.  The  Wasscrmann  re- 
action was  positive.  The  plate  shows  the  condition 
after  some  treatment  with  mercury,  potassium  iodide, 
Zittman  and  0.3  salvarsan. 


144 


Plate  XIX.     Fig.  22 


PLATE   XX 

Figure  23.— Gummatous  Destruction  of  tiie' 
Soft  Palate 


Figure  23.— Gummatous  Destruction  of  the 
Soft  Palate 

The  soft  palate  on  either  side  of  the  raphe  is  en- 
tirel}^  destroj-ed.  Only  the  uvula  and  lower  part  of 
the  anterior  pillars  of  the  fauces  remain  intact. 
Through  the  perforation  the  posterior  pharyngeal 
wall  can  be  seen,  from  which  a  band  of  connective  tis- 
sue extends  to  the  remaining  part  of  the  posterior 
surface  of  the  soft  palate.  On  the  free  borders 
of  the  perforations,  mother-of-pearl  colored  cicatrices 
are  seen.  Scars  are  also  to  be  observed  on  the  pos- 
terior wall  of  the  pharynx.  The  inflammatory  pro- 
cess has  ceased. 

The  patient,  a  woman  thirty-five  years  old,  had 
an  inflanmiation  of  the  throat  nine  years  previously 
which  healed  after  inunctions  were  administered. 
Since  then  no  treatment  was  taken. 

For  several  years  a  large  ulcer  existed  on  the 
thigh.  Six  weeks  previous  to  the  condition  as  seen  in 
the  plate  there  was  difficulty  in  swallowing.  At  the 
time  the  patient  entered  the  hospital  she  was  much 
run  down,  and  on  the  left  thigh  there  were  a  deep 
gummatous  ulcer,  as  large  as  the  palms  of  two  hands, 
and  several  small  gummata.  The  soft  palate  on  both 
sides  was  perforated.  The  borders  of  the  perfor- 
ations were  ulcerated  and  ulcers  also  existed  on  the 
posterior  wall  of  the  pharynx.  ^Vll  of  the  ulcers  had 
a  dirty  grayish  covering.  The  Wassermann  reaction 
was  positive. 

After  an  intraiuuscnlar,  and  intravenous  injec- 
tion of  salvursan  the  tluoat  ulcerations  healed  entirely 
within  three  weeks,  while  the  gummata  of  the  skin 
diminished  greatly  in  size  within  six  weeks.  The 
patient  gained  Ki  pounds.  The  plate  shows  the  con- 
dition of  the  soft  palate,  etc.,  wlicn  the  patient  left  the 
hosjjital.  Speaking  and  swallowing  were  not  inter- 
fered with. 


148 


Plate  XX.     Fig.  23 


PLATE  XXI 

Figure  24.— Ulceration  of  tlie  Fauces  in 
Malignant  Sypliilis 


Figure  24.— Ulceration  of  the  Fauces  in 
IVIalignant  Syphilis 

The  entire  left  anterior  and  posterior  pillars  of  the 
fauces,  almost  all  of  the  uvula  and  the  left  tonsil  are 
ulcerated,  so  that  there  is  a  deep  destruction  of  the 
mucous  and  submucous  tissue.  The  floor  of  the  ulcer 
is  covered  with  a  markedly  adherent  white  diphthe- 
roid necrotic  membrane.  The  wall  of  the  ulcer  is  pre- 
cipitous. The  surrounding  mucous  membrane,  to 
a  considerable  distance  from  the  ulcer,  is  actively  con- 
gested, oedematous,  and  swollen.  To  the  left  of  the 
large  ulcer  is  a  small  one  having  a  sharp  border  and 
tending  to  unite  with  the  large  one.  The  patient,  a 
woman  fifty-one  years  old,  had  eight  to  ten  weeks 
previously  a  chancre  of  the  lower  lip  with  a  submaxil- 
lary adenitis.  At  the  time  when  the  ulceration  of  the 
fauces  occurred  there  were  no  skin  manifestations,  but 
there  was  a  periosteal  gumma  of  the  right  tibia.  The 
Wassermann  reaction  was  positive. 

The  ulcer  had  much  the  appearance  of  a  gumma 
rapidly  undergoing  necrosis,  which,  in  conjunction 
with  the  presence  of  the  periosteal  gumma  of  the  tibia 
and  its  occurrence  in  the  first  weeks  after  infection,  is 
especially  characteristic  of  malignant  syphilis.  The 
age  of  the  patient  may  be  looked  upon  as  predispos- 
ing to  the  malignant  course  of  the  disease.  Local 
treatment  of  the  ulcers  with  bichloride  of  mercury  in 
glycerine  (2%)  and  inunctions  of  mercury  caused  a 
rapid  disappearance  of  the  lesions. 


152 


Plate  XXI.    Fig.  24 


PLATE  XXII 

Figure  25.— Malignant  Sypliiiis  of  tlie 
Fauces 


Figure  25.— Malignant  Syphilis  of  the 
Fauces 

The  entire  soft  palate,  the  uvula  and  anterior  and 
posterior  pillars  of  the  fauces  have  been  destroyed  by 
a  syphilitic  ulcer.  On  the  edge  of  the  lesion  is  a 
large  ulcer,  with  precipitous  walls  surrounded  by  a 
not  very  extensive  bright  red  border.  The  floor  of 
the  ulcer  is  covered  with  a  strikingly  yellow  adherent 
membrane,  but  there  is  no  oedematous  swelling.  On 
the  posterior  pharyngeal  wall  similar  ulcers  can  be 
seen. 

The  destructive  process  has  probably  been  going 
on  for  several  weeks,  but  the  patient  could  make  no 
definite  statement  regarding  his  condition. 

Syphilis  had  been  acquired  about  six  months 
previously.  Inunctions  had  been  given  for  four  or 
five  weeks  without  much  result,  when  a  macular  erup- 
tion and  the  ulcerated  angina  appeared.  Under 
potassium  iodide  and  biniodide  of  mercury  improve- 
ment took  place.  Some  months  later  the  patient  re- 
turned in  the  present  condition.  There  were  several 
deep  ulcerated  syphilides  on  the  skin  and  one  on  the 
skull  which  reached  the  periosteum.  The  marked 
destructive  changes  which  took  place  in  the  first  year 
of  the  disease  designate  the  case  as  one  of  malignant 
syphilis. 


156 


Plate  XXII.     Fig.  25 


PLATE  XXIII 

Figure  26.— Syphilis  Hereditaria 
(Heredosypliilis) 


Figure  26.— Syphilis  Hereditaria 
(Heredosyphilis) 

In  this  case  a  severe  papular  syphilide  of  the  en- 
tire face  is  seen,  especially  about  the  anterior  nares 
and  the  mouth.  The  syphilitic  infiltrate  is  particularly 
dense  and  deep.  Radiating  furrows  are  seen,  which 
will  later  on  form  radiating  scars,  characteristic  of 
heredosyphilis.  In  one  of  the  mucous  patches  about 
the  angle  of  the  jaw  treponemata  pallida  were  found. 

This  child  was  born  of  a  syphilitic  mother,  who 
had  early  secondary  manifestations  of  the  disease. 
Four  weeks  after  birth  there  appeared  an  eruption  on 
the  body  of  the  child  followed  by  that  on  the  face. 
Aside  from  the  presence  of  the  treponema  pallidum 
in  the  lesions  and  otherwise  characteristic  syphilitic 
changes,  the  eruption  is  not  likely  to  be  confused  with 
any  other  disease.  Eczema  might  be  thought  of  were 
it  not  that  in  eczema  we  do  not  find  the  individual  pap- 
ules and  vesicles,  and  there  is  no  marked  formation 
of  crusts.  The  penetrating  character  of  the  infiltrate 
and  the  formation  of  the  radiating  fissures  are  against 
a  diagnosis  of  eczema. 


ICO 


Plate  XXIII.     Fig.  26 


PLATE  XXIV 

Figure  27.— Syphilis  Hereditaria  Tarda 
(Late  Heredosypiiiiis) 


Figure  27.— Syphilis  Hereditaria  Tarda 
'  (Late  Heredosyphilis) 

This  is  a  typical  case  showing  the  entire  stigmata 
of  heredosyphihs.  This  case  shows,  besides  the  well- 
known  Hutchinson  triad  (parenchymatous  keratitis, 
otitis  and  Hutchinson  teeth) ,  a  marked  protrusion  of 
the  frontal  protuberances,  saddle  nose  and  radiating 
scars  about  the  mouth.  The  radiating  scars  in  the 
vermilion  and  skin,  which  have  come  from  the  deep 
fissures  in  the  syphilitic  infiltrate,  are  pathognomonic 
of  heredosyphilis.     (Compare  Fig.  26.) 


164 


Plate  XXIV.     Fig.  27 


PLATE  XXV 

Figure  28.— Syphilis  Hereditaria  Tarda  (Late 
Heredosyphilis).    Gumma  of  tiie  Tongue 

Figure  29.— Syphilis  Hereditaria  Tarda  (Late 
Heredosyphilis).  Gummatous  Perfora- 
tion of  the  Hard  Palate  and  Heredo- 
syphilitic  Teeth 


Figure  28.— Syphilis  Hereditaria  Tarda  (Late 
Heredosyphilis).    Gumma  of  the  Tongue 

In  the  middle  of  the  tongue,  extending  almost 
through  its  entire  length,  is  a  deep  linear  scar  with 
a  number  of  radiating  scars.  The  patient,  sixteen 
years  old,  who  denied  ever  having  contracted  syphilis, 
was  admitted  to  the  hospital  for  gonorrhoea.  On  the 
root  of  the  nose  was  a  typical  gummatous  ulcer  about 
2.5  cm  in  diameter,  which  had  existed  for  about  two 
months.  Two  years  previously  he  had  ulcers  on  the 
tongue,  all  but  one  of  which  had  healed  completely. 
The  Wasscrmann  reaction  was  positive. 

Since  the  other  stigmata  of  heredosyphilis  are  ab- 
sent and  the  family  history  is  negative  regarding 
syphilis,  the  diagnosis  of  syphilis  acquired  in  early  life 
might  be  made,  but  the  diagnosis  of  heredosyphilis  is 
probably  the  correct  one  in  this  case. 


Figure  29.— Syphilis  Hereditaria  Tarda  (Late 
Heredosyphilis).  Gummatous  Perfora- 
tion of  the  Hard  Palate  and  Heredo- 
syphilitic  Teeth 

On  the  hard  palate  is  a  deep  perforating  ulcer 
covered  with  pus  and  with  a  dirty  membrane  and  hav- 
ing a  foul  smelling  exudate.  The  bones  of  the  nose 
have  become  necrosed.  Sequestra  have  been  dis- 
charged from  the  nose  and  there  is  ozcena.  The  ulcer 
developed  within  two  months.  The  Wasscrmann  re- 
action was  j)ositive. 

The  patient  was  thirteen  years  old,  had  a  paren- 
chymatous keratitis,  but  there  was  no  family  history 
of  syphilis.    The  teeth  are  seen  better  in  Fig.  67. 


168 


r 


Plate  XXV.     Figs.  28,  29 


PLATE  XXVI 

Figure  30.— Stomatitis  IVIercuriaiis  (iVIercu- 
rial  Stomatitis) 

Figure  31.— Stomatitis  IVIercuriaiis.  Mercu- 
rial Stomatitis  with  Ulcerations  on  the 
Border  of  the  Tongue 


Figure  30.— Stomatitis  IVIercurialis  (iVIercu- 
riai  Stomatitis) 

This  is  a  case  of  a  severe  general  ulcerated  stom- 
atitis. The  niucous  membrane  of  the  entire  mouth  is 
very  red  and  swollen.  The  gums  are  necrotic  and 
covered  with  a  yellowish  membrane  containing  pus. 
Pus  can  be  pressed  out  of  the  alveoli  for  the  teeth. 
The  tongue  is  greatly  swollen,  and  hollowed-out  ul- 
cers, covered  with  pus,  are  to  be  seen  along  its  edge 
at  points  opjjosite  the  teeth. 

The  mucous  membrane  of  the  lips  is  very  much 
swollen  and  ulcers  caused  by  pressure  from  the  teeth 
are  seen.    There  was  marked  salivation  and  foetor. 


Figure  31.— Stomatitis  Mercurialis.  IMercu- 
riai  Stomatitis  with  Ulcerations  on  the 
Border  of  the  Tongue 

A  woman,  twenty-six  years  old,  with  early  syphi- 
lis, syphilitic  angina,  psoriasis  palmaris  and  a  severe 
mercurial  stomatitis,  was  admitted  to  the  hospital.  For 
fourteen  days  she  had  taken  inunctions,  without  tak- 
ing any  care  of  her  mouth.  The  entire  mucous  mem- 
brane of  the  mouth  was  inflamed  and  the  tongue  was 
coated.  On  the  edge  of  the  tongue  were  several  hol- 
lowed-out ulcers  with  very  red  borders  and  covered 
with  yellowish-gray  adherent  necrotic  membranes. 
These  ulcers  corresponded  to  the  adjacent  teeth  and 
might  be  regarded  as  decubital  ulcers. 

As  there  are  signs  of  early  syphilis  present  these 

173 


ulcerations  might  be  falsely  diagnosed  as  those  of 
secondary  syphilis,  but  the  number  and  regular  ar- 
rangement, together  with  their  smooth  floors  covered 
with  necrotic  membranes,  distinguish  them  from  the 
ulcers  of  secondary  syphilis.  In  secondary  syphilis 
the  floor  of  the  ulcer  is  irregular  and  anfractuous,  and 
has  a  grayish  border.  The  flat  form  of  the  pictured 
ulcers  and  their  number  preclude  also  a  diagnosis  of 
gumma.    The  ulcers  healed  under  simple  treatment. 


174 


Plate  XXVI.     Figs.  30,  31 


Reprinted  from  The  Journal  of  Cutaneous  Diseases,  Including 
Syphilis,  for  April,  IQl^. 

BOOK    REVIEWS 

DERMOCHROMES.  Text  by  Jkroaie  Kingsbury,  M.D.,  attending  Physician, 
New  York  Skin  and  Cancer  Hospital;  Physician  for  Diseases  of  the  Skin  to 
the  Presl)yterian  Hospital  Dispensary;  Member  of  the  American  Dermato- 
logical  Association;  Member  of  the  New  York  Dermatological  Society,  etc. 
Chapters  on  Syphilis  by  William  Gaynor  States,  M.D.,  Assistant  Surgeon, 
New  York  Polyclinic  Hospital;  Fornurly  Instructor  in  Genito-Urinary  Dis- 
eases; .Member  of  the  American  Medical  Association;  Member  of  State  and 
County  Medical  Society  of  New  York;  M'est  Side  Clinical  Society,  etc.  With 
■2tiH  colored  illustrations  and  6  half-tone  figures.  Bound  in  full  flexible 
leather  with  gilt  edges.  3  vols.  Price,  $H.OO  net.  Rebman  Co.,  Ul-145 
W.  36th  Street,   New   York. 

As  stated  in  the  preface  "this  portfolio  of  dermochromes  contains  266  colored 
and  6  black  and  white  illustrations.  All  of  the  colored  plates  are  from  Jacobi's 
Atlas  der  Hautkrankheiten,  and  217  of  the  figures  appeared  in  the  fourth  Ameri- 
can addition  of  this  work,  known  here  as  the  Jacobi  Dermochromes.  The  remain- 
ing +9  figures  are  from  the  fifth  German  addition  of  the  Atlas,  and  are  now,  by 
arrangement  with  the  German  publisher,  presented  for  the  first  time  in  this  coun- 
try. The  black  and  white  illustrations,  representing  different  types  of  alopecia, 
are   from   photographs   taken   by   William    B.   Trimble." 

The  Portfolio,  then,  is  a  new  edition  of  the  Jacobi-Pringle  Dermochromes,  with 
the  addition  of  many  new  colored  figures  and  half-tone  illustrations.  It  is  pub- 
lished, as  before,  in  three  volumes.  For  those  who  possess  the  Jacobi  Dermo- 
chromes a  single  volume  has  been  prepared,  which  contains  the  new  text  and  the 
new  illustrations. 

The  new  edition  is  edited  by  Jerome  Kingsbury,  who  has  written  an  entirely 
new  dermatological  text.  A  perusal  of  this  text  shows  that  the  editor  has  care- 
fully studied  the  authoritative  text-books,  added  this  to  a  knowledge  gained  by 
long  exiierienctf  in  dermatology,  and  then  evolved  a  description  of  the  various  dis- 
eases, which  is  concise,  sufficiently  complete,  accurate  and  a  pleasure  to  read.  It 
seems  to  us  that  this  text  admirably  fulfils  its  purpose,  which  is  not  that  of  a 
text-book,  but  rather  an  attempt  to  convey  to  the  student,  by  words  and  pictures, 
an  accurate  general  conception  of  the  diseases  contained  in  the  work. 

Pringle's  text  in  the  former  edition  was  very  good,  but  the  new  text  is  more 
complete  and  has  brought  the  various  subjects  "up-to-date";  also  it  has  been  writ- 
ten especially   for  American  physicians. 

.  Among  the  272  illustrations  are  found  practically  all  of  the  common  derma- 
toses, inchuling  most  of  the  cutaneous  syphilitic  manifestations,  and,  also,  many  of 
the  rartr  forms  of  skin  diseases.  The  colored  reproductions  are  superb,  and  faith- 
fully depict  the  diseases  as  seen  in  life.  With  one  possible  exception,  the  new  half- 
tones materially  add  to  the  value  of  the  work.  We  refer  to  the  i)icture  of  syphilitic 
alopecia.  It  would  seem  advantageous  to  obtain  a  clearer  description  of  the  char- 
acteristic "nioth-eiilen"  ap])earance. 

We  note  thai  there  is  a  l)etter  gronjiing  of  the  plates,  and,  also,  an  improved 
and  complete  index. 

.Stalls  has  given  a  good  general  onlline  of  syphilis.  To  deal  with  such  a  huge 
subject  in  so  small  a  space  is  indeed  a  difficult  task.  We  feci  that  more  emphasis 
could  have  been  placed  upon  .sy))hilis  as  a  general  disease.  While  we  realize  that 
there  can  be  no  niutine  trentment  of  .syphilis,  yet  it  would  seem  wise  to  guide  the 
physician  in  a  concise  nuinner  in  the  mniiagement  of  the  disease  from  the  time  of 
infection  throughout  the  entire  course  of  the  aflfection,  explaining  the  indications 
for  routine  anil  for  special  measures.  We  would  appreciate,  also,  seeing  a  few 
American  names  among  the  foreign  cpiotations. 

The  viiluines  are  beautifully  bound  in  leather,  well  iirinti-d  on  excellent  paper, 
and  are  e\<(|itionally  artistic.  Thi-re  are  a  few  typographical  errors,  that  should 
be  corrected   in  the  next  edition. 

'1  hi'  I'lirtfipliii  will  be  of  value  to  skilled  dermatologists  for  teaching  purposes. 
It  would  sum  invaluable  to  students,  general  practitioners  and  physicians  in  spe- 
cialties iillicr  than  dennaliilogj'  and  for  dermatologists  who  have  not  the  clinical 
facilities   found  only   in  large  cities.  O.  M.  M. 


PLATE   XXVII 

Figure  32.— Angina  Mercuriaiis  (IVIercuriai 

Angina) 


Figure  32.— Angina  IVIercurialis  (Mercurial 

Angina) 

A  syphilitic  young  woman  was  given  several  in- 
jections of  mercury,  whereupon  an  acute  severe  in- 
flammation of  the  throat  followed.  The  mucous 
membrane  of  the  fauces  became  intensely  red,  oedema- 
tous  and  swollen.  On  the  soft  palate  and  uvula  was 
an  extensive  white  necrotic  adherent  membrane  giv- 
ing the  aj)pearance  of  a  severe  diphtheria.  The 
tongue  was  badly  coated  and  the  mucous  membrane 
of  the  entire  mouth  red.  Salivation  was  present.  On 
the  gums,  the  usual  place  of  predilection  for  mer- 
curial stomatitis,  there  was  no  membrane  or  ulcera- 
tion.    The  temperature  was  only  slightlj^  raised. 

The  patient  deceived  her  parents  and  physicians 
about  her  having  taken  mercury.  The  diagnosis  of 
diphtheria  was  made  and  the  patient  was  sent  to  the 
department  for  infectious  diseases  in  the  hospital. 
The  slight  fever  and  the  good  general  condition  of 
the  patient  did  not  agree  with  the  severe  local  mani- 
festations. The  Klehs-Ldfflcr  bacillus  was  sought  for 
again,  but  not  found.  Later  on  distinct  swelling  of 
the  border  of  the  gums  apjieared,  which  indicated  the 
mercurial  poisoning.  From  the  appearance  of  the  le- 
sion the  first  diagnosis  (diphtheria)  was  justified. 


178 


Plate  XXVII.    Fig.  32 


PLATE  XXVIII 

Figure  33.— Antipyrin  (Salipyrin)  Exanthem 
of  the  Tongue 

Figure  34.— Liciien    Ruber    Planus    of    tlie 
Buccal  Mucous  Membrane 


Figure  33.— Antipyrin  (Salipyrin)  Exanthem 
of  the  Tongue 

An  old  man,  several  hours  after  taking  0.5  gram 
of  salipyrin,  developed  a  severe  inflammation  of  the 
month.  There  was  a  marked  burning  sensation  and 
congestion  and  swelling  of  the  mucous  membrane. 
The  tongue  was  swollen  and  its  surface  became  rough : 
bullae,  which  soon  ruptured,  formed  upon  the  lips  and 
gums. 

The  mucous  membrane  of  the  tongue  fell  to 
pieces,  especially  on  the  base  of  the  tongue,  which 
was  denuded  of  epithelium.  The  anterior  part  of  the 
tongue  was  markedly  coated.  After  using  camomile 
tea  as  a  moutli  wash,  healing  began  in  a  few  days.  The 
patient  said  that  some  years  previously,  after  taking 
antipyrin,  he  developed  bulls  in  his  mouth,  but  the 
attack  was  not  so  severe  as  this  one.  The  sudden  ap- 
pearance directly  after  taking  the  drug,  the  sponta- 
neous healing  and  the  previous  occurrence  of  similar 
manifestations  after  the  administration  of  antipyrin 
indicate  a  medicamentous  exanthem. 


Figure  34.— Lichen    Ruber    Planus    of    the 
Buccal  Mucous  Membrane 

On  the  mucous  membrane  of  the  cheeks,  a  number 
of  mother-of-pearl  gray  pajiules  are  seen.  They  are 
umbilicated  and  ringlike,  with  a  diameter  of  about 
2  or  3  mm.  The  rings  coalesce  here  and  there,  shaping 
themselves  like  the  figure  8.    Near  the  angle  of  the 

183 


mandible  the  papules  are  the  largest,  and  they  grad- 
ually dmiinish  in  size  to  the  angle  of  the  mouth 
where  they  become  little  dots.  In  this  ease  the  diag- 
nosis was  easy,  both  on  account  of  the  characteristic 
form  of  the  lesion,  and  because  there  was  also  a  typi- 
cal lichen  ruber  on  the  body.  In  similar  cases  the 
papules  may  coalesce,  forming  patches  which  greatly 
resemble  mucous  patches,  or  they  may  be  more  um- 
bilicated  and  thus  form  greater  efflorescences  of  less 
characteristic  appearance.  If  there  is  no  accompany- 
ing eruption  on  the  skin  it  may  be  difficidt  to  make 
a  diagnosis,  o\\'ing  partly  to  the  fact  that  efflores- 
cences on  the  mucous  membrane  are  far  more  re- 
fractory to  arsenic  than  are  those  of  the  skin. 


184 


Plate  XXVIII.    Fig*.  33,  34 


PLATE  XXIX 

Figure  35.— Erythema  Exudativum  Multi- 
forme of  tlie  Mucous  Membrane  of  tlie 
Mouth.  (Idiopathic  Polymorphous  Ery- 
thema) 


Figure  35.— Erythema  Exudativum  Multi- 
forme of  the  Mucous  Membrane  of  the 
Mouth.  (Idiopathic  Polymorphous  Ery- 
thema) 

Some  days  after  the  occurrence  of  a  typical  ery- 
thema multiforme  exudativum  upon  the  hands  and 
feet  of  a  man  thirty  years  old,  a  similar  eruption  ap- 
peared upon  the  mucous  membrane  of  the  lips  and 
cheeks.  Large  buUfe  developed  upon  the  lower  lip, 
which  ruptured  soon  after  their  contents  had  coagu- 
lated. Only  one  in  the  centre  of  the  lower  lip  main- 
tained its  bloody  contents.  The  mucous  membrane 
was  covered  with  crusty,  yellowish,  markedly  ad- 
herent fibrinous  membranes.  When  these  were 
removed  the  excoriated  surfaces  bled  easily.  On  the 
mucous  membrane  of  the  upper  lip  and  cheek  large 
bulht  did  not  form,  but  small  excoriations  are  seen 
surrounded  by  pieces  of  epithelial  debris.  Here  the 
process  has  passed  the  climax.  The  surrounding  in- 
flammatory reaction  is  slight.  The  diseased  part  is 
(juite  sharply  marked  off  from  the  sound  tissue  by 
a  zone  of  loosened  epithelium.  The  affection  is  very 
painful,  and  the  patient  can  only  take  fluids. 

Syphilis  can  scarcely  be  confused  with  it.  The 
sudden  appearance  of  the  eruption  on  the  mucous 
membrane  and  the  synchronous  appearance  of  a  typi- 
cal erythema  multiforme  exudativum  on  the  extremi- 
ties make  the  correct  diagnosis.  So  extensive  and  in- 
tensive an  involvement  of  the  mucous  membrane  as 
is  seen  here  does  not  often  occur.  One  is  reminded 
of  an  antipyrin  exanthem  when  examining  these  le- 
sions. 


188 


Plate  XXIX.    Fig.  35 


PLATE  XXX 

Figure  36.— Herpes  Labialis  (Herpes  of 
the  Lip) 


Figure  36.— Herpes  Labialis  (Herpes  of 
the  Lip) 

This  patient  had  syphilis  and  was  given  an  intra- 
venous injection  of  salvarsan.  He  reacted  the  same 
evening  with  a  high  fever.  Next  morning  the  herpes 
appeared.  On  the  vermihon  and  the  bordering  skin 
a  group  of  small  vesicles  appeared  which  partly  co- 
alesced. The  contents  of  the  vesicles,  at  first  clear, 
quickly  coagulated.  The  surrounding  skin  was 
slightly  congested.  In  this  case  these  manifestations, 
characteristic  of  herpes,  cannot  easily  be  mistaken 
for  the  characteristic  manifestations  of  syphilis.  One 
can  perceive  in  the  plate  the  way  the  herpes  began  at 
the  arched  borders  of  the  lesion.  When  the  herpes 
exists  only  as  a  single  group  of  small  vesicles  on  the 
vermilion  or  mucous  membrane  (especially  in  its  last 
stage  when  the  vesicles  have  ruptured  and  the  coagu- 
lated contents  are  discharged)  it  may  resemble  an 
eroded  mucous  patch.  It  is  not  always  easy  to  diag- 
nose herpes,  close  examination  and  study  of  the  case 
are  frequently  necessary. 


192 


Plate  XXX.     Fig.  36 


PLATE   XXXI 

Figure  37.— Aphthous  Ulcer  (Aphthous  Sto- 
matitis) 

Figure  38.— Angina  Foliicularis  Catarrhaiis 
(Follicular  Tonsillitis) 


Figure  37.— Aphthous  Ulcer  (Aphthous  Sto- 
matitis) 

On  the  middle  of  the  lower  lip  is  a  flat  hollowed- 
out  little  ulcer  with  a  yellowish- white  covering  and  an 
acutely  inflamed  border.  It  was  very  painful  and 
had  a  sudden  onset.  The  sudden  onset,  the  pain  and 
the  active  inflammatory  reaction  existing  together 
disfavor  a  diagnosis  of  syphilis,  but  when  the  pain  and 
inflanmiatory  reaction  are  absent,  it  is  difficult  to 
diagnose  this  lesion  from  an  erosive  mucous  patch. 
Aphthous  ulcers  of  the  mouth  occasionally  occur  in 
syphilitics.  The  finding  of  the  treponema  pallidum 
in  the  lesion,  which  is  always  easy  in  erosive  mucous 
patches,  makes  the  diagnosis. 


Figure  38.— Angina  Foliicularis  Catarrhalis 
(Follicular  Tonsillitis) 

In  this  case  there  is  an  acute  inflanmiation  of  the 
isthmus  of  the  fauces  accompanied  with  fever.  There 
is  much  congestion  and  swelling  so  that  the  isthmus 
of  the  fauces  is  narrowed.  The  tonsils  are  also  swol- 
len. Projecting  from  the  lacunte  of  the  tonsils  are  to 
be  seen  the  yellowish  white  plugs  which  contain  pus 
cells. 


196 


Plate  XXXI.     Figs.  37,  38 


PLATE  XXXII 

Figure  39.— Angina  Sypliilitica  et  Angina 
Foillcularis  Catarrlialis  (Syphilitic  An- 
gina and  Follicular  Tonsillitis) 

Figure  40.— Diphtheria 


Figure  39.— Angina  Syphilitica  et  Angina 
Foliicularis  Catarrlialis  (Sypliiiitic  An- 
gina and  Follicular  Tonsillitis) 

The  patient  was  being  treated  for  secondary 
syphilis.  The  manifestations  were  a  chancre  of  the 
right  labium  majus,  a  papulo-squamous  syphilide,  im- 
petigo capitis,  and  a  syphilitic  angina.  Shortly  after 
the  beginning  of  the  treatment  there  occurred  a  severe 
inflammation  of  the  fauces,  the  tonsils  became  swollen 
and  the  follicles  were  filled  with  plugs  containing  pus, 
accompanied  by  fever  and  difficulty  in  swallowing. 
The  easily  seen  gray  mucous  patchlike  edge  of  the 
syphilitic  angina  persisted  after  the  angina  foliicu- 
laris had  healed. 


Figure  40.— Diphtheria 

There  is  an  active  inflammation.  The  tonsils  are 
but  slightly  swollen.  A  grayish-white,  markedly  ad- 
herent membrane  lies  on  the  left  anterior  and  pos- 
terior pillars  of  the  fauces,  left  tonsil,  left  half  of  the 
soft  palate  and  uvula,  and  extends  to  the  posterior 
pharyngeal  wall.  There  is  not  much  coating  of  the 
tongue.  In  this  case  the  constitutional  symptoms 
were  very  slight.  There  was  no  high  fever.  The 
diagnosis  of  diphtheria  was  based  on  the  sharp  line  of 
demarcation  between  the  white  markedly  adherent 
membrane  and  the  surrounding  red  actively  inflamed 
mucous  meml)rane,  on  the  fact  that  the  lesion  devel- 
oped in  two  days  and  finally  upon  the  conclusive  evi- 
dence, viz.:  the  Klcbs-Lojjlcr  bacilli  in  the  lesion. 


200 


Plate  XXXII.     Figs.  39,  40 


PLATE   XXXIII 

Figure  41.— Plaut-Vincent  Angina  (Ulcer- 
ated Angina  Resembling  a  Chancre  of 
the  Tonsil) 

This  very  instructive  case  is  one  of  a  young  man, 
eighteen  years  old,  who  came  to  the  hospital  with  an 
inflamed  throat.  About  three  or  four  weeks  previ- 
ously he  had  attended  a  masked  ball  and  became  very 
intimate  with  an  unknown  young  woman  whom  he 
kissed  a  great  deal.  When  he  came  under  observation 
the  lesion  was  a  characteristic  chancre  of  the  tonsil. 
The  right  tonsil  was  swollen,  but  the  surrounding 
mucous  membrane  was  not  especially  congested. 

There  was  not  much  pain,  and  on  palpation  the 
lesion  was  quite  firm. 

On  the  side  and  anterior  surface  of  the  tonsil  there 
was  an  elliptical  ulcer  with  arched-shaped  borders 
about  2  cm  long  and  1  cm  wide.  Its  hollowed-out 
floor  was  covered  by  a  greenish-yellow,  markedly  ad- 
herent, fibrinous  membrane.  At  the  angle  of  the 
mandible  on  the  right  side  there  were  two  movable 
indolent  lymph  ganglia,  one  of  which  was  about  the 
size  of  an  almond  and  the  other  a  little  smaller. 
There  was  little  doubt  but  that  the  lesion  was  a 
chancre.  Before  giving  an  injection  of  salvarsan,  as 
no  secondary  manifestations  of  the  disease  had  ap- 
peared, the  treponemata  pallida  were  sought  in  the 
lesion,  but  none  were  found,  though  the  eff'ort  to  find 
them  was  continued  for  several  days.  However,  a 
large  number  of  thick  spirilla  were  detected,  and  in  a 

203 


stained  specimen  numerous  fusiform  bacilli  were  also 
disco  ^'ered. 

As  the  treponema  pallidum  was  not  found  on  the 
ulcer  the  submaxillary  lymph  nodes  were  punctured 
daily  for  several  days  and  their  aspirated  fluid  care- 
fully examined,  but  with  negative  result.  Local 
treatment  was  begun,  which  consisted  of  gargling  the 
throat  with  weak  hydrogen  peroxide  and  painting  the 
lesion  with  30%  hydrogen  peroxide.  After  a  few 
days  the  ulcer  became  clean  and  healed;  the  tonsil 
became  softer  and  the  swelling  disappeared ;  the  sub- 
maxillary lymph  nodes  diminished  in  size,  and  after 
fourteen  days  there  was  no  trace  of  the  disease,  ex- 
cepting a  slight  swelling  of  the  lymph  nodes.  The  pa- 
tient was  kept  under  regular  observation  for  several 
weeks.  There  was  no  manifestation  of  syphilis,  and 
the  W assermann  reaction  which  was  at  first  negative 
remained  so. 

This  is  a  case  of  a  non-specific  ulcer  of  the  tonsil, 
which,  in  view  of  the  microscopic  findings,  viz.:  spi- 
rilla and  fusiform  bacilli,  is  to  be  classed  in  the  Plant- 
Vincent  angina  group.  This  case,  in  which  nobody 
believed  the  lesion  to  be  anything  other  than  a  chancre 
of  the  tonsil,  shows  how  careful  one  must  be  in  mak- 
ing a  diagnosis,  even  when  aided  by  the  findings  of 
the  dark-field-microscope,  as  it  occasionally  happens 
that  the  spiroclijcta  dentium  (treponema  microden- 
tium)  and  especially  "the  mediimi  form"  (treponema 
macrodentium)  may  be  found,  and  these  are  often 
difficult  to  distinguish  morphologically  from  the  tre- 
ponema pallidum. 


204 


Plate  XXXIII.     Fig.  41 


PLATE  XXXIV 

Figure  42.— Angina  Ulcerosa  Traumatica 
(Ulcerated  Traumatic  Angina).  (Plaut- 
Vincent  Angina?) 

A  man  in  good  health,  forty-two  years  old,  who 
emphatically  denied  ever  having  had  syphilis,  had  a 
foreign  body  stick  into  the  soft  palate  near  the  uvula. 
A  small  pustule  developed.  After  some  days  a  phy- 
sician removed  the  foreign  body  from  this  pustule. 
The  resulting  small  ulcer  did  not  heal,  but  gradually 
increased  in  size,  so  that  in  about  four  weeks  it  had 
a  diameter  of  about  6  nmi,  and  as  a  crescentic  ulcer  in- 
volved the  upper  part  of  the  left  anterior  pillar  of  the 
fauces.  When  the  patient  came  under  our  observa- 
tion, the  ulcer  had  almost  completely  healed,  except- 
ing the  serpiginous  part  which  had  extended  to  the 
left  pillar  of  the  fauces,  where  there  was  seen  a  hol- 
lowed-out  ulcer  about  the  size  of  a  lentil  with  a  yel- 
lowish-white floor.  The  scar  felt  quite  firm.  The 
surrounding  mucous  membrane  was  red,  oedematous, 
and  swollen.  There  was  but  slight  pain  and  little 
difficulty  in  swallowing. 

The  diagnosis  swung  at  first  between  gumma  and 
chancre.  Against  tuberculosis,  aside  from  the  form 
of  the  ulcer  and  the  absence  of  tubercles,  was  its  oc- 
currence and  partial  healing  within  four  weeks.  The 
absence  of  adenopathy  precluded  the  diagnosis  of 
chancre,  although  a  suspicious  eruption  occurred 
which  was  found  to  be  a  medicamentous  acne  caused 

207 


by  taking  potassium  iodide.  The  treponema  pal- 
lidum was  not  found  in  the  lesion,  although  there  were 
a  number  of  coarse  thick  spirilla  present.  The  fusi- 
form bacillus  was  absent.  The  Wassermann  was 
negative,  hence  the  diagnosis  of  gumma  was  not  made. 
An  energetic  treatment  with  potassium  iodide  had 
no  effect.  The  possibility  of  actinomycosis  was  not 
excluded.  When  one  part  healed,  other  small  ulcer- 
ations slowly  extended  along  the  left  anterior  pillar 
of  the  fauces.  Diligent  gargling  with  camomile  tea 
and  2%  hydrogen  peroxide  had  no  effect.  After 
four  weeks,  when  the  lesion  was  rubbed  several  times 
a  day  with  30%  of  hydrogen  peroxide,  the  process 
quickly  came  to  a  standstill.  The  patient  remained 
for  some  time  under  observation.  No  secondary 
manifestations  of  syphilis  or  relapsing  of  ulcerations 
were  seen.  The  Wassermann  reaction  remained  neg- 
ative. Carcinoma  was  thought  of,  but  the  healing  and 
the  entire  course  of  the  disease  excluded  such  a  diag- 
nosis. 

This  case  was  an  ulcero-serpiginous  inflammation 
of  the  mucous  membrane  of  the  fauces  of  traumatic 
origin,  which  is  to  be  classed  among  the  Plant-Vin- 
cent angina  group,  although  the  spirilla  and  fusi- 
form bacilli  could  not  be  found  in  the  lesion. 


208 


Plate  XXXIV.     Fig.  42 


PLATE  XXXV 

Figure  43.— Angina  Mycotica  (IMycotIc 
Angina) 


Figure  43.— Angina  IVIycotica  (IVIycotic 
Angina) 

The  mucous  membrane  of  the  fauces  is  neither  red 
nor  swollen.  In  the  follicles  of  the  tonsils  which  are 
not  enlarged,  yellowish-white  keratogenous  plugs  are 
seen  extending  several  niillimetres  above  the  mucous 
membrane.  The  plugs  can  be  squeezed  out  of  the 
follicles  and  appear  by  microscopic  examination  to  be 
composed  of  masses  of  epithelium,  calcareous  mate- 
rial, and  threads  of  fungi  (Leptothrix  Buccalis). 


212 


Plate  XXXV.     Fig.  43 


PLATE   XXXVI 

Figure  44.— Lingua  Geographica  (Tiie  Geo- 
graphical Tongue) 

Figure  45.— Lingua  Geographica  (The  Geo- 
graphical Tongue) 


Figure  44.— Lingua  Geograpliica  (Tlie  Geo- 
graphical Tongue) 

The  entire  tongue  is  somewhat  coated.  The  epi- 
thelium is  thickened  and  arranged  in  the  form  of  bows 
and  garlands.  There  is  no  swelling  or  pain.  The 
differential  diagnosis  of  this  condition  from  an  an- 
nular syphilide  of  the  tongue  was  not  easy,  and  there- 
fore the  fact  that  the  patient  had,  six  weeks  before, 
a  not  very  characteristic  ulcer  in  the  coronary  sulcus 
was  of  considerable  importance.  No  treponemata 
pallida  were  found,  the  Wassermann  reaction  was 
negative  and  there  was  an  inflammatory  adenitis  in 
the  left  inguinal  region. 

As  the  patient  insisted  he  had  had  these  white 
bows  on  his  tongue  from  childhood,  and  as  in  the 
course  of  the  further  observation  no  manifestations  of 
secondary  syphilis  appeared,  the  diagnosis  of  syphilis 
was  excluded. 


Figure  45.— Lingua  Geograpliica  (The  Geo- 
graphical Tongue) 

This  is  a  form  of  lingua  geographica  which  very 
greatly  resembles  a  papular  syphilide  of  the  mucous 
membrane  of  the  tongue.  On  the  tongue  are  to 
be  seen  round  and  elliptical,  quite  smooth  bluish-red 
spots,  surrounded  by  a  narrow  darker  red  border 
which  is  also  surrounded  by  a  whitish  border  of  thick- 
ened epithelium.  There  is  no  infiltration,  the  mucous 
membrane  of  the  rest  of  the  tongue  being  normal. 

Without  great  care  the  efflorescence  cannot  be  dis- 

217 


tinguished    from    smooth    mucous    patches    of    the 
tongue. 

In  this  case  the  diagnosis  was  especially  difficult 
as  the  patient  also  had  syphilis.  This  affection  of  the 
tongue,  however,  had  existed  since  childhood  and  was 
not  affected  by  the  inunctions  of  mercury,  which  the 
patient  had  taken.  The  appearance  of  the  tongue 
rapidly  changed,  so  that  in  a  few  days  the  form  and 
arrangement  of  the  spots  were  entirely  altered. 


218 


Plate  XXXVI.    Figs.  44,  45 


PLATE  XXXVII 

Figure  46.— Leukoplakia  Linguae  (Leuko- 
plakia of  the  Tongue) 

Figure  47.— Tuberculosis  of  the  Mucous 
Membrane  of  the  Hard  Palate 


Figure  46.— Leukoplakia  Linguae  (Leuko- 
plakia of  the  Tongue) 

In  a  man,  seventy  years  of  age,  who  had  syphilis 
in  his  youth,  the  mucous  membrane  of  the  entire 
mouth  was  altered,  becoming  thickened  and  callous- 
like,  and  of  a  dull  gray  appearance,  permitting  the 
red  of  the  underlying  tissue  barely  to  show  itself  and 
feeling  dry  and  hard.  The  entire  surface  of  the 
tongue  was  divided  into  small  fields  by  numerous  fine 
furrows  arranged  in  a  reticular  manner.  In  sep- 
arated localities  the  thickening  of  the  epithelium  led 
to  the  formation  of  a  horny  layer,  especially  on  the 
cheeks.  On  the  left  border  of  the  tongue,  opposite 
some  sharp  stumps  of  teeth,  a  sort  of  ulceration  oc- 
curred, but  there  was  no  pus  and  the  lesion  was  cov- 
ered with  epithelium.  This  lesion  may  be  the  begin- 
ning of  carcinoma  of  the  tongue,  as  it  has  been 
observed  for  over  a  year,  and  no  change  has  taken 
place  in  it. 


Figure  47.— Tuberculosis  of  the  Mucous 
Membrane  of  the  Hard  Palate 

In  this  case  the  diseased  mucous  membrane  is 
intensely  congested,  with  a  rough,  granular  surface 
which  has  hollowed-out  small  irregular  and  in  part 
recticular  ulcers  with  precipitous  borders  scattered 
over  it.  The  floor  of  the  ulcers  is  covered  with  a 
greenish-yellow  pus  and  their  form  makes  clear  their 
origin  from  miliary  tubercles.  The  mucous  mem- 
brane of  the  soft  palate  is  thickly  covered  with  tu- 
bercles somewhat  resembling  sago.  Tubercle  bacilli 
were  not  found  in  the  pus.  The  patient  suffered  from 
a  severe  lupus  of  the  face  and  uuicous  membrane  of 
the  nose,  which  extended  to  the  uaso-pharynx. 


222 


Plate  XXXVII.    Figs.  46,  47 


PLATE  XXXVIII 

Figure  48.— Tuberculosis  of  tlie  IVIucous 
iVIembrane  of  the  Fauces,  Soft  Palate, 
and  Uvula 


Figure  48.— Tuberculosis  of  tlie  fViucous 
IVIembrane  of  tlie  Fauces,  Soft  Palate, 
and  Uvula 

The  entire  mucous  membrane  of  the  fauces,  soft 
palate,  and  uvula  is  much  congested,  oedematous,  and 
swollen.  The  surface  of  the  mucous  membrane  is 
finely  granular  or  velvetlike.  On  the  uvula  and  soft 
palate  there  are  several  small,  hoUowed-out  ulcera- 
tions with  undermined  edges.  It  can  be  seen  that 
these  ulcers  arise  from  the  confluence  of  numerous 
miliary  tubercles.  The  ulcers  are  covered  with  yel- 
lowish-white pus.  The  process  gradually  extends 
over  the  normal  mucous  membrane.  Tubercle  bacilli 
were  not  found  in  the  pus,  but  an  extirpated  por- 
tion of  the  mucous  membrane,  which  was  rubbed  up 
with  normal  saline  solution  and  injected  into  the  peri- 
toneal cavity  of  a  guinea-pig,  produced  tuberculosis 
in  the  animal. 

The  patient  is  a  w^ak  anitmic  child,  six  years  old, 
and  suffers  also  from  a  pannus  scrophulosus  of  both 
eyes  and  an  eczema  of  the  scalp. 


226 


Plate  XXXVIII.     Fig.  4a 


PLATE  XXXIX 

Figure  49.— A  Tubercular  Ulcer  of  the 
Lower  Lip 


Figure  49.— A  Tubercular  Ulcer  of  the 
Lower  Lip 

In  this  case  a  deep,  painful  nicer  is  seen  on  the 
lower  lip  of  a  moribund  phthisical  patient.  It  has  ex- 
isted less  than  four  months.  It  involved  the  right 
half  of  the  lower  lip  and  extended  to  the  gums  and 
the  mucous  membrane  of  the  right  cheek.  The  floor 
of  the  ulcer  is  granular  and  humped  up,  and  in  the 
hollows  and  furrows  a  small  amount  of  yellow  pus  is 
seen  which  contained  tubercle  bacilli.  Separating 
the  normal  mucous  membrane  on  the  left  side  of  the 
lip  from  the  ulcer  is  a  precipitous  border  which  in 
some  places  is  2  or  3  mm  high. 


230 


Plate  XXXIX.    Fig.  49 


PLATE   XL 
Figure  50.— Carcinoma  of  the  Tongue 
Figure  51.— Tumor  of  the  Tongue.  Gumma? 

Figure  50.— Carcinoma  of  the  Tongue 

On  the  left  side  of  the  tongue  is  a  tumor  about 
2  cm  in  diameter.     The  border  of  the  tumor  is  pre- 
cipitous and  rampartlike,  and  extends  2  or  3  mm 
above  its  level.    It  is  as  hard  as  cartilage  and  forms 
a  sharp  line  of  demarcation  between  the  normal  tis- 
sue and  the  tumor.     The  ulcerated  humped  up  sur- 
face of  the  tumor  is  flattened  or  somewhat  concave, 
is  covered  with  tenacious  pus  and  bleeds  easily.    The 
tumor,   which   is   situated   opposite   a   sharp   tooth, 
gradually  developed  from  a  small  ulcer  during  the 
course  of  three  months.     It  is  quite  painfid.     No  in- 
volvement of  the  adjacent  lymph  nodes  was  seen. 
Even    without    a    negative    Wassermann    and    the 
absence  of  the  treponema  pallidum  in  the  lesion  a 
diagnosis  of  carcinoma  can  be  made.     The  compact- 
ness of  the  rampartlike  border  was  too  great  for  a 
chancre,  and  besides  there  would  be  evidence,  at  this 
time,  of  the  involvement  of  the  adjoining  lymph 
nodes  and  of  the  secondary  syphilitic  manifestations. 
The  development  was  too  slow  and  the  breaking  down 
too  slight,  and  the  tumor  itself,  and  especially  its  bor- 
der, too  hard  for  it  to  be  mistaken  for  a  gumma. 
Tuberculosis  was  to  be  thought  of,  but  the  tubercle 
granula  were  absent.    A  biopsy  confirmed  the  diag- 
nosis. 

Figure  51.— Tumor  of  the  Tongue.  Gumma? 

A  man,  thirty  years  of  age,  came  under  observa- 
tion who  had  a  tumor  of  the  tongue  situated  to  the 
right  of  its  median  line.  It  consisted  of  two  nodes 
situated  one  beside  the  other,  each  being  about  the 
size  of  a  hazel  nut.     The  tumor  gradually,  in  the 

233 


course  of  some  weeks,  developed.  There  was  quite  a 
sharp  line  of  demarcation  between  it  and  the  sur- 
rounding normal  tissue.  It  Avas  firm  and  painless. 
There  was  a  dictinct  central  softening  in  both  nodes, 
which  in  the  course  of  a  few  days  approached  the  sur- 
face, and  final!}'  a  graj'ish-yellow  color  appeared  over 
the  spot.  The  patient  said  that  ten  years  previously  he 
had  had  a  chancroid  which  quickly  healed  after  ap- 
plying iodoform,  and  following  which  there  were  no 
secondary  manifestations  of  syphilis.  The  Wasser- 
■mann  reaction  was  and  continued  to  be  negative. 
The  lymph  nodes  in  the  neck  were  slightly  swollen. 
On  puncturing  the  tumors,  a  greenish,  viscid,  gela- 
tinous mass  was  obtained,  but  the  tumor  could  still 
be  distinctly  felt.  Under  small  doses  of  potassium  io- 
dide the  tumor  very  quickly  disappeared  without  leav- 
ing a  scar.  It  is  very  doubtful  if  tliis  was  a  gunmia  of 
the  tongue.  The  appearance  of  the  tumor,  the  way  in 
which  it  developed,  and,  finally,  the  central  softening, 
favor  the  diagnosis  of  gumma.  The  exceptionally 
rapid  and  spontaneous  healing  after  the  administra- 
tion of  the  potassium  iodide  is  striking.  That  the 
Wassermann  reaction  continued  negative  proves 
nothing,  even  if  it  gives  weight  to  a  diagnosis  exclud- 
ing syphilis. 

A  malignant  tumor,  carcinoma,  or  sarcoma  could 
not  run  such  a  course.  It  was  not  an  abscess,  as  there 
was  no  i)ain  and  the  softened  spot  did  not  contain 
pure  pus,  but  cell  detritus. 

Actinomycosis  was  thought  of,  l)ut  the  micro- 
scopic examination  did  not  prove  the  presence  of  the 
actinomyces.  Echinococcosis  was  thouglit  of,  as  the 
patient  liad  a  dog  which  lie  had  rc])catcdly  treated 
for  tape  worms.  IJut  licre  proof  was  lacking.  It 
must  be  clearly  understood  that  in  the  beginning  this 
tumor  was  not  a  cystic  tumor,  but  that  it  was  a  com- 
pact tumor,  which  underwent  softening  at  the  centre. 
That  is  why  it  cannot  be  a  retention  cyst. 

In  this  case  wlicrc  the  lesion  closely  resembles  a 
gumma,  the  diagnosis  must  be  left  open  on  account  of 
insufficient  proof. 

234 


Plate  XL.     Figs.  50,  51 


PLATE   XLl 
Figures  52,  53.     Hutchinson  Teeth 
Figures  54-57. ^Herodosyphilitic  Teeth 


Figures  52,  53.— Hutchinson  Teeth 

The  two  upper  central  incisor  teetli.  whicli  are  oval 
in  shape,  have  a  deep  notching  of  their  niorsal  mar- 
gin; otherwise  the  teeth  are  perfectly  smooth  and  nor- 
mal. The  left  upper  lateral  incisor  tooth  is  round 
and  pointed.  A  central  caries  of  the  two  upper  first 
molars  (which  evidently  resulted  from  the  hypoplasia 
of  the  morsal  surface  of  the  teeth)  is  also  seen. 

The  teeth  are  those  of  a  girl  sixteen  years  old 
who  has  heredosyphilis  and  a  parenchymatous  kerati- 
tis. 

The  lower  first  molars  were  completely  destroyed. 


Figures  54-57.— Herodosyphiiitic  Teeth 

In  this  case  the  teeth  of  a  ten-year-old  girl  show  a 
high  grade  of  disturhance  during  the  period  of  cal- 
cification. The  two  upper  central  incisor  teeth  are 
well-marked  Hulchinson  teeth,  each  with  its  charac- 
teristic, crescentic  notch.  These  two  teeth  arc  l)ro:ul, 
but  narrow  toward  the  morsal,  and  gingival  luargiiis 
and  their  outer  edges  are  pointed.  The  two  upper 
lateral  incisor  teeth  have  eroded  morsal  margins.  The 
I  wo  upper  canine  teeth  are  misplaced  and  have  sliarj)- 
pointed  eroded  tips. 

The  four  lower  incisor  teeth  show  a  supcrticiai 
hv])oplasia,  extending  from  the  middle  of  the  crown 
to  the  morsal  margin.  The  lower  canine  teeth  arc 
eroded  at  their  tips. 

The  morsal  surfaces  of  the  entire  four  first  molars 
are  distinctly  eroded.  Instead  of  the  normal  smooth 
cusps  there  are  numerous  irregular,  wrinkled,  granu- 
lar points. 

In  striking  contrast  to  the  teeth  witli  the  dcvclop- 
mcntal  hypo|)lasia,  notice  the  smooth  noi'ina!  morsal 
surfaces  of  the  cuspid,  bicuspid,  and  other  molar 
teeth. 

238 


Plate  XLl.     Figs.  52,  53,  54,  55,  56,  57 


PLATE    XLII 
Figures  58-61.— Herodosyphiiitic  Teeth 
Figure  62.— Heredosyphiiitic  Teeth 


Figures  58-61.— Herodosyphilitic  Teeth 

This  case  also  demonstrates  a  lii^li  tjrade  of  liy- 
poplasia.  especially  of  the  two  up])er  central  incisor 
teeth.  The  entire  distal  third  is  diminished  in  size 
in  all  directions,  and  the  hypoplasic,  amorphons  por- 
tion of  each  of  these  teeth,  without  any  enamel,  rests 
ui)on  the  normal  part  of  the  teeth  as  a  hase.  This 
condition  resend)les  the  notching  of  the  Iliifchiiison 
teeth,  witli  the  difference  that  here  the  disturhance  to 
the  calcification  jjroeess  lasted  longer.  The  upper  la- 
teral incisor  teeth  are  a  little  worn  away  at  tlie  mor- 
sal  margins.  The  upper  and  lower  canine  and  the 
lower  incisor  teeth  show  a  high  grade  of  hypoplasia 
toward  their  morsal  margins.  The  hypoplasia,  on 
the  morsal  surfaces  of  the  fom-  first  molar  teeth,  is 
especially  marked.  Here  the  dirty  yellow  humped- 
up  morsal  sui'face  of  the  teeth  is  situated  upon  the  re- 
maining normal  part  of  tlie  tooth. 

The  cuspid,  bicuspid,  and  the  other  molar  tcetli, 
so  far  as  they  are  preserved,  are  perfectly  developed. 


Figure  62.~Heredosyphiiitic  Teeth 

Shows   an   especially    marked    hypoplasia   of   the 
morsal  surfaces  of  the  lirst  molar  teetli. 


242 


Plate  XLII.     Figs.  58,  59,  60,  61,  62 


PLATE   XLIII 
Figures  63-66.— Heredosyphilitic  Teeth 
Figure  67.— Heredosyphilitic  Teeth 


Figures  63-66.     Heredosyphilitic  Teeth 

Krosions  in  llic  lorm  of  j)its  are  seen  n])()n  tlie 
two  ii])])er  central  and  all  the  lower  incisor  teeth, 
i]])()ii  l>olh  tiic  niorsal  inaruins  and  the  facial  snrfaces 
of  the  crowns.  AW  fonr  canine  teeth  show  a  liypo- 
plasia  of  their  ti])s.  which  ajjpcar  as  if  thcv  were  se[)- 
arated  from  the  rest  of  the  tooth  hy  a  Hat  fiii-row. 
The  ui)])cr  first  molar  teeth  also  have  an  cncirclinn' 
furrow,  which  is  the  line  of  (U'Miarcation  between  the 
hy])o])lasia  of  the  morsal  surfaces  and  the  remaining' 
normal  ])ortion  of  the  teeth.  One  of  the  lower  molars 
is  missino^,  and  hut  little  of  the  other  is  left.  The 
condition  of  the  first  molars,  which  must  he  attributed 
to  the  damage  done  before  birth,  Mas  probably 
caused  bv  heredosyphilis.  which  is  also  to  be  regarded 
as  the  cause  of  the  erosions  in  the  form  of  pits  and 
hollows. 

The  patient  probably  had  heredosyphilis.  A  sis- 
ter had  Hutchinson  teeth  and  a  parenchymatous 
keratitis. 


Figure  67.— Heredosyphilitic  Teeth 

On  the  facial  surfaces  of  all  the  upper  and  lower 
incisor  and  canine  teeth  are  several  furrows  and  cup- 
like erosions,  and  all  their  morsal  margins  are  notched 
in  several  places.  All  the  first  molars  are  missing, 
except  tlie  right  lower  one,  in  which  there  is  a  central 
caries,  apparently  following  a  developmental  hypo- 
plasia of  the  morsal  surface.     The  cusj)id  and  bicus- 

247 


pid  teeth  show  on  their  surfaces  shght  erosions  and 
transverse  furrows. 

This  is  the  result  of  a  condition  existing  before 
birth  and  continuing  to  the  end  of  the  first  or  part  of 
the  second  year  of  life. 

The  history  of  this  case  is  very  instructive.  The 
patient,  a  boy.  twehe  years  old,  had  been  treated  a 
year  and  a  half  for  a  j^arencliyniatous  keratitis.  The 
diagnosis  of  syphilis  was  not  made,  and  antisyphilitic 
treatment  was  not  energetically  applied,  because  the 
keratitis  did  not  react  well  to  mercury;  the  Wasser- 
maiin  reaction  was  negative,  there  were  no  other 
symptoms  of  heredosyphilis,  and  the  condition  of  the 
teeth  was  attributed  by  me,  at  that  time,  to  rachitis. 

A  year  later  the  boy  returned  with  a  severe  syphi- 
litic perforation  of  the  hard  ])alate  (compare  Fig. 
29)  and  a  positive  Wasscnnann  reaction.  If  the 
hypoplasia  of  the  right  lower  first  molar  had  been 
recognized  as  a  sign  of  heredosyphilis  and  energetic 
antisyphilitic  treatment  resorted  to,  the  patient  would 
have  been  spared  the  severe  disfigurement. 


248 


Plate  XLIII.     Figs.  63,  64,  65,  66,  67 


PLATE    XLIV 

Figure  68.— Treponema  Pallidum  (Spiro- 
chaeta  Pallida).  The  Specimen  was  Ob- 
tained from  a  Mucous  Patch  of  the  Lip 

Figure  69.  -Spirochaeta  Buccalis  and  Spi- 
rochaeta  Dentium  (Treponema  Micro- 
dentium).  The  Specimen  was  Obtained 
from  a  Healthy  Mouth 


Figure  68.— Treponema  Pallidum  (Spiro- 
chaeta  Pallida).  The  Specimen  was  Ob- 
tained from  a  Mucous  Patch  of  the  Lip 

Six  treponemata  pallida  are  seen  in  the  dark  field. 
Thev  are  shown  here  as  straioht  or  sliylitlv  curved 
spirilla,  with  jjointed  ends,  and  havina:  seven  to  ei^ht 
turns.  They  move  slowly  hy  rotating  ahout  tlieir 
axes.  There  are  also  flexion  and  extension  move- 
ments. 


Figure  69. — Spirochaeta  Buccalis  and  Spi- 
rochaeta  Pentium  (Treponema  Micro- 
dentium).  The  Specimen  was  Obtained 
from  a  Healthy  Mouth 

The  S|)iroeha^ta  Bueealis  is  thicker  than  tlu'  pal- 
lida, and  has  irregular  turns  and  an  active  snakelike 
or  flagellating  movement. 

The  Spirocha'la  Dentium  is  finer  than  the  pallida, 
and  its  very  regular  windings  are  closer  and  its  curve; 
steeper  than  those  of  llic  jjallida.  Tlie  Si)iroch;et;i 
Dentium  moves  ahout  its  long  axis,  and  its  movement 
is  not  so  ra])id  as  the  spirochieta  huccalis. 


252 


Plate  XLIV.     Figs.  68,  69 


PLATE    XLV 

Figure  70.  Treponema  Pallidum,  Pus  Cells, 
Erythrocytes,  and  Cocci 

Figure  71. —Treponema  Microdentium  (Spi- 
rochaeta  Pentium),  Treponema  IVIacro- 
dentium  ("  Medium  Form  "  of  Hoffmann 
and  von  Prowazek),  Spirochaeta  Buc- 
calis 


Plate  XLV.     Figs.  70,  71 


70 

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PLATE   XLVI 

Figure  72.^Spirochaeta  off  Vincent  and  Ba- 
cillus Fusiformis  off  Vincent,  Pus  Cells 

Figure  73.— The  Chronology  off  the  Calciffi- 
cation  off  the  Teeth 


Plate  XLVI.     Figs.  72,  73 


Fig.  72 


YE»RS 


MONTHS 


»T  BIRTH 

wecKs 


DECIDUOUS     TEETH 


PERMANENT    TEETH 


THE    CHRONOLOGY     OE    THE      CHLCiriC»TION     OE    THE     TEETH 

Fig.  73 


INDEX 


INDEX 


Abscess,  cntarrhni,  18 

tonsillar,  18 
Alcoholism,  :i-2,  38 
Alopecia,  24,  10-2,  106 
Amyloid    degeneration,   3 
Aneurism,  3 
Angina,  5,  18,  106 

foUicularis,  52,  196,  200 

mcrcurialis,  178 

mycotica,  212 

Plaut-Vincent,  8,    19,   53,   203, 
20T 

syphilitic,  25,  116,  132,  200 

traumatic,   207 

ulcerosa,  132,  203,  207 
Annulus  migrans,  56 
Antipyrin,  47 

exanthem,  183 
Arteriosclerosis,  3 
Atrophy,  smooth,  34 

Bacillus  fusiformis  of   Vincent,  8, 

259 
Balsamics,  47 
Bednar's  aphthae,  46 
Bony  defects,  30 
Buccal    mucous   membrane,   liclien 

of,  183 
Burri.  method  of,  9 

Cachexia,  32 

Calmette,   ophthalmic   reaction   of, 

63 
Cancrum  oris,  53 
Carcinoma,  10,  59,  64,  233 
Caries,  42 
Chancre,  1 

extragenital,  15 

genital,   15 

hypertrophied,   IS 

on  cheeks,  17 

on   gums,   17 

on  lip,  14,  70,  74 


Chancre,  on  palate,  17 

on   tongue,   15,  78 

on   tonsils,   17 

papular,  15 

soft,  19 

ulcerated,   15 
Chancroid,   16,   19 
Cheeks,  chancre  on,  17 
Condylomata   lata,   4,  20,  26,  86 
Coryza,  35 
Cuti-reaction,  63 

Dark-field  microscope,  9 

Deflection   of  the  complement,   10 

Dementia  paralytica,  3,  10 

Dentin  cap,  37 

Dentin,  formation  of,  37 

Dermatitis  herpetiformis,  49 

Diagnosis  ex  juvantil)us,  62 

Diphtiieria,  5,  36,  200 

Disea-ses  similar  to  lesions  of  sec- 
ondary syphilis  of  the 
mouth,  45 

Diseases  similar  to  lesions  of  tertia- 
ry syphilis  of  the  mouth,  59 

Dtierey  -  Krefting  streptobacillus, 
19 

Dunkelfcid  microscope,  9 

Ectwlerm,  20 
Eczema,  48 

Kmhryo,  infection  of,  3 
Embryonic  cells,  2 
Entoderm,  20 

Erosions,  chancrous,  14,  70 
Eruptions,   medicamentous,  47 
Erythema,      idiopathic      polymor- 
phous, 49 

multiforme     cxudativum,     49, 
188 

syphilitic  of  the  mouth,  82 
Erythematous  spots,  21 
Exanthem,  21 


265 


Fauces,    annular   syphilide   of,   134 
malignant  syphilis  of,  156 
tuberculosis  of,  226 
ulceration  of,  153 

Foetus,  infection  of,  3 

Foot  and  mouth  disease,  54 

Frambcsia,  7 

Frenuni  linguae,  45 

Fungi,  54 

Furuncles  on  lip,  18 

Gastroenteritis,   39 
Geograjihical   tongue,  55,  216 
Giemsa  stain,  9 
Glossitis,  chronic  interstitial,  24 

diffuse,  21. 

syphilitic,  111 
Gumma,  6,  168,  333 
Gums,  chancre  on,  17 

Hard  i>alate,  30,  140,  144,  168,  320 
Heredosyphilis,  4,  34,  160 

late,  36,  164,  168 
Heredosyphilitic  child,  13 
Herpes  facialis,  50 
Herpes  labialis,  192 
Hutchinson  teeth,   41,  338 
Hutchinson  triad,  39 
Hyperemia  of  the  isthmus,  31 
Hypoplasia,   developmental,   36 

India  ink  method,  9 
Intradermic   reaction,  63 
Introduction,  i 

Keratitis,  6 

Klebs-Loeffler  bacillus,  53,   300 

Latent  sypliilis,  10 
Lcontiasis,  31 
Leprosy,  10 
Leptothrix  buccalis,  54 
Lesion,  initial,  1 

primary,  1,  13,  16 

fecondary,   2 

tertiary,  2,  6 
leukoderma   colli,   103 
IxMikoplakia  buccalis,  5,  56 
Ix!ukoplakia  lingure,  333 
Lichen   ruber  planus,  48,  183 
Lingua  geographica,  55,  217 
Lingua   lobata,  31 
Lingua  ])licata,  55 


Lip,  annular  s\-i)hilide  on,  102 
chancre  on,  14,  70,  74 
chapped,  13 
eczema  of,  12 
erosive  mucous  patches  on,  86, 

90 
furuncles  on,   18 
herpes  of,  192 
hypertrophied   mucous  patches 

on,  94 
papulo-ulccrated    syphilide  of, 

94 
tubercular  ulcer  of,  230 
ulcerated   syjihilidc  of,  98 
Lues  hereditaria  tarda,  36 
Luetin,  11 

Martotix'  intradermic   reaction,  63 
Measles,  48 

Medication,  palliative,  63 
Mercurial   stomatitis,  46 
Microdentism,  43 
Microscojie,  9 
Migranin,  47 

Mouth,    circinate    raucous    patches 
of,  136 

erythema  multiforme  of,  188 

syphilitic  erythema  of,  83 
Mucous  patches,  6,  20,  35,  86,  90, 
94,  9S,   106,  111,  138,  136 

hyiiertrophied,  2-2 

opaline,  22 

ulcerated,   23 

Naso-labial  folds,  condylomata  lata 

of,   86 
Nccrol)iosis,  2 
Necrosis,  2 
Neoplasia,  30 

Nochujii  luetin   reaction,   11,  67 
Noma,  53 
Nose,  circinate  mucous  patches  of, 

136 

Ophthalmic   reaction,  63 
Orchitis,  6 

Palate,  30,  33 

chancre  on,  17 

ulcers  on,  46 
Piilute,  hard,  gummatous  ulcers  of, 
MO 

perforation  of,  30,  144,  168 

tul)crculosis  of,  220 


266 


Palate,  soft,  annular  sypliilidc  of, 
12 1 

giininiatous       destruction     of 
118 

liyiUTtro]ihicd     muooiis    patch 
of,   lis 

mucous  patches  of,  120 

tuberculosis  of,  •226 
Papules,  6,  130 
Parasyphilosis,  -2 
Poinjihipus,   19 
Periostitis,  -l,   1-U 
Phenncetin,  47 
Plan,  7 

Pirquet,  cuti-reaction  of,  63 
Plaque  muqueuse,  33 
Plaque  opaline,  23 
Point  of  infection,  3 
Post-syphilitic  diseases,  10 

manifestations,  2 
Processus     alveolarius,     periostitis 

of,  lU 
Psoriasis,  49 

Purpura  hemorrhagica,  SO 
Pyramidon,  47 

Rachitis,  39 

Reaction  of  fixation,  9 

Roseola,  6 

Salipyrin,  47 

exanthem,  183 
Scarlatina,  10,  48 
Sclerosis  of  the  tongue,  24,  31 

primary,  1 
Secondary  period,  1 
Sero-reaction,  9 
Skin  diseases,  48 
Soft  palate,  33 

Spirochata  buccalis,  8,  252,  255 
Spirochaeta  Caatallani,  8 
Spirochaeta  dentium,  6,  9,  352 
Spirochaeta  Loexcenthalii,  7 
Spirochaeta  microgirata,  7 
Spirochaeta  of  Vincent,  8,  259 
Spirochaeta  pallida,  1,  253 
Spirochaeta  pallidula,  7 
Spirochaeta  pertenuis,  7 
Spirochaeta  rcfringens,  7 
Stomacace,  53 
Stomatitis,  36 

aphthous,  50,  196 

ganprenous,  53 

maculo-fibrosa,  50 


Stomatitis,  mercurial,  46,   173 

panisitic-niyotic,  51 

ulcerative,  53 
Syphilide,    annular,    24,    9ri,     102, 
124 

circinatc,  24,  26 

cutaneous,  20,  106 

erosive,  23 

mucous,  30 

orbicular,  21. 

papular,  28,  60,  106 

tertiary,  2 
Syphilis,  congenital,  34 

hereditary,  4,  34,  160,  164 

intrauterine,  38 

latent,  10,  36,   164,  168 

malignant,  32,  152,  156 

primary,  12 

secondary,  20,  66 

tertiary,  28,  144 

transmission  of,   13 
Systemic  diseases,  10 

Tabes,  3,  10 

Teeth,  absence  of,  43 

asj-metrical,  43 

chronologj'  of  the  calcification 
of  the,  259 

heredosy|ihilitic,   168,  242,  247 

sharklike,  43 

twisted,  43 
Tertiary  period,  1 
Test  teeth,  41 

Throat,  syphilitic  sore  of,  25 
Thrush,  5,  51 

Tongue,    antipyrin    exanthem    of, 
183 

carcinoma  of,  233 

chancre  on,  15,  78 

erosive  mucous  patches  of,  90 

geographical,  55,  216 

gumma  of,  168 

hypertrophied  mucous  patches 
of,  94 

leukoplakia  of,  220 

opaline     mucous     patches     of, 
106 

papulo-ulcerated   sj-philide  of, 
94,   106 

ulcerated   mucous   patches  of, 
111 

tumor  of,  233 
Tonsillitis,  follicular,  52,  196,  200 
Tonsils,  chancre  on,  17,  203 


267 


Trauma,  5-t  Ulcer,  serpiginous,   102 

Treponema  macrodentium,  8,  255  tubercular,  230 

medium  form,  8  Ultra-microscope,  9 

Treponema    microdentium,     6,  7,       Uvula,  annular  sj-philide  of,  IS-t 

252,  255  hypertrophied  mucous  patches 

Treponema  pallidum,  1,  5,  20,  35,                   of,  120,  12S 

38,  66,  252,  255  tuberculosis  of,  226 

Treponema  pertenue,  8 

Tropical  diseases,  10  Varicella,  48 

Tubercular   ulcers    of    the   mouth, 

60 

~  ,         ,.             ..        _„  A\  anderine  rash.  56 

Tuberculin  reaction,  63  '^ 

T,  ,         ,     .      n„    „o    cnn   m/;  Wassermann  reaction,  9 
Tuberculosis,  10,  3b,  222,  226 

of  the  mouth,  59  ^^'^^  n"^«^'  ^^ 

Typhoid  fever,  38  Wolff-Eisner,   ophthalmic   reaction 

■^'                   '  of,  63 

Ulcer,  aphthous,  50,  196 

reticulated,  28  Yaws,  7 


268 


LIST    OF    AUTHORS 


Bordet.  9 
BriK-k,  9 
Burri.  9 

Calmcttc,  63 
Castallani,  8 
Cohn,  8 

Ducrey-Krefting,    19 

Fournier,  12 

Gengou,  9 

Hoffmann,  9 

Hutchinson,   39,   41,   43,   164 

Klebs-Loeffler,  52 
Koch,  7,  8 

Martoux,  G3 


Neisscr,  9 
Nocliugi,  11,  67 

Metchnikoff,  6 

Pirquet,  63 

Plaut- Vincent,  19,  S3 

Prowaczck,  8 

Roux,  6 

Srhaiidinn,   5 

Vincent,  9 

Wassennann,  9 
Widal,  9 
Wolff-Eisner,  63 

Zittmann,   lOfi,   144 


269 


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